Contact Medicaid Care Management Organizations (CMOs), File a Complaint about a Licensed Facility, Facebook page for Georgia Department of Community Health, Twitter page for Georgia Department of Community Health, Linkedin page for Georgia Department of Community Health, YouTube page for Georgia Department of Community Health, Ground Ambulance (Public/Private) Providers, Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC), Medicaid Sign-Up Portal (Georgia Gateway). Reimbursement Policies | Georgia - Medicaid | CareSource The payment rate for out-of-state enrolled hospitals will not exceed 65% of covered charges. These rates are inclusive of 13.37% Growth and audited 2018 GL/PL Insurance Costs. Resources for Audiologists Medicaid Toolkit: What Audiologists Need to Know Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by Peach State Health Plan. The goals of this endeavor will be implemented. Effective January 24, 2021 a significant enhancement to our physician reimbursement policies that promote correct coding. Reimbursement Policies. MEDICAL POLICY STATEMENT GEORGIA MEDICAID - CareSource The Initial Reimbursement rates for FYE June 30, 2021, are located below. According to Georgia Medicaid guidelines, EPSDT services should only be billed as frequently as allowed in the Georgia Medicaid Manual, any services above and beyond this frequency will be recommended for denial. American Speech-Language-Hearing Association Call 1-800-GEORGIA to verify that a website is an official website of the State of Georgia. For out-of-state enrolled hospitals, payments are made at the statewide average percentage of charges paid to Georgia hospitals that are reimbursed at 85.6% of costs and are not subject to cost settlement. Policies in the Peach State Health PlanClinical Policy Manual may have either a Peach State Health Planor a Centene heading. Please locate the pdf file where the Provider's Name would fall. endstream endobj 456 0 obj <>/Metadata 27 0 R/Pages 453 0 R/StructTreeRoot 49 0 R/Type/Catalog/ViewerPreferences 472 0 R>> endobj 457 0 obj <>/MediaBox[0 0 612 792]/Parent 453 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 458 0 obj <>stream Physical, Occupational, and Speech Therapy Services (PDF) CP.MP.49: June 30, 2021: . Therapy Comply is a healthcare compliance firm that seeks to bring high quality web-based compliance guidance and one-on-one consulting services to small and medium size physical, occupational, and speech therapy practices. 0 doctor, request an ID Card and more. Division of Health Benefits. The CMOs authorize and reimburse services through provider networks found here: Amerigroup: https://www.myamerigroup.com/ga/georgia-home.html, Wellcare: https://www.wellcare.com/Georgia, Peach State: https://www.pshpgeorgia.com/, Care Source: https://www.caresource.com/ga/, The National Suicide Prevention Lifeline is a United States-based suicide prevention network of 161 crisis centers that provides a 24/7, toll-free hotline available to anyone in suicidal crisis or emotional distress. An official website of the State of Georgia. If you are at an office or shared network, you can ask the network administrator to run a scan across the network looking for misconfigured or infected devices. 558.5. hVQo8+zz$[! Each payment rule is sourced by a generally accepted coding principle. Additionally, laws and regulations and insurance and payer policies are subject to change. In addition, Peach State Health Planmay from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendors guidelines may also be used to determine whether a service has been correctly coded. 471 0 obj <>/Filter/FlateDecode/ID[<467E25C1DCB7FA4CA9B5341409AF092E>]/Index[455 37]/Info 454 0 R/Length 91/Prev 216195/Root 456 0 R/Size 492/Type/XRef/W[1 3 1]>>stream PDF 74.88 KB - January 05, 2022 Division/Office. %PDF-1.7 % They are routinely updated to promote accurate coding and policy clarification. These reimbursement policies apply to our Georgia Medicaid plans. occupational therapy, and services for individuals with speech, hearing and language disorders; . How you know. Monday to Friday, 08:00 a.m. - 05:00 p.m. All in Eastern Time Zone. Please note that the reimbursement rate sheets (R-32) are in alphabetical order. Fee-For-Service | Georgia Medicaid Diaphragm fitting, condoms and contraceptive injection of medroxyprogesterone acetate must be submitted with modifier FP (Service provided as part of Medicaid family planning program). Press Tab or Shift+Tab to navigate through menu. All Contacts. They are routinely updated to promote accurate coding and policy clarification. Examples of provider administered drugs: Copyright 2023 Wellcare Health Plans, Inc. Behavioral Health and Rehabilitation Services, Durable Medical Equipment and Supplies - Enteral Nutrition, Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services, Family Planning Services Contraceptives, U1 (Practitioner Level 1) - U6 (In-Clinic), U1 (Practitioner Level 1) - U7 (Out-of-Clinic), U2 (Practitioner Level 2) - U6 (In-Clinic), U2 (Practitioner Level 2) - U7 (Out-of-Clinic), U3 (Practitioner Level 3) - U6 (In-Clinic), U3 (Practitioner Level 3) - U7 (Out-of-Clinic), U4 (Practitioner Level 4) - U6 (In-Clinic), U4 (Practitioner Level 4) - U7 (Out-of-Clinic). \ w|p&buSa!HTNH8zEl&~taFZ>qy|Zu_i-gF7*K_xhM |ykr\5fOy6wAT)+EhK4 9IOfUFJ?!A9Hkz Gv&v>QeIY1.?yL.Tv?{!% Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding. Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules. All rights reserved. Medicaid reimbursement rates and associated policy of this program are found here: Provider Manuals. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. All policies found in the Peach State Health Plan Clinical Policy Manual apply to Peach State Health Plan members. Clinical Payment Policy | Georgia Medicaid | Peach State Health Plan Policies in the Peach State Health PlanPayment Policy Manual may have either a Peach State Health Planor a Centene heading. Under managed care, Georgia pays a fee to a managed care plan for each person enrolled in the plan. You may access the InterQualSmartSheet(s) for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling Peach State Health Plan. Reimbursement rates have been recalculated effective July 1, 2020 through June 30, 2021. Open the pdf and scroll down to the Provider R-32 you need and print. Send a Message. 1997- American Speech-Language-Hearing Association. <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Before sharing sensitive or personal information, make sure youre on an official state website. The National Drug Code (NDC) is a unique, three-segment number that identifies a drug. The information contained in this web site is intended as general information only. Speech_Audio_COVID_Rate_Ext FS to 1-31-22.pdf. Georgia Medicaid 3a, Col 003, line 019: 36) Capital Related - Buildings & Fixtures (All Agencies Statewide) Sch. All rights reserved. 491 0 obj <>stream According to Georgia Medicaid guidelines, certain provider administered drugs must be reported with the National Drug Code (NDC) that corresponds directly to the drug related procedure code. Reimbursement policies are designed to assist you when submitting claims to CareSource. If you do not have Adobe Acrobat Reader, you may download ithere. 04/01/2023. Non-Member: 800-638-8255, Site Help | AZ Topic Index | Privacy Statement | Terms of Use Press Enter on an item's link to navigate to that page. Providers and their office staff are encouraged to use self-service channels to verify member eligibility. The claims review process takes into consideration WellCare historical claims edits as well as edits from the following sources: WellCare payment policies focus on areas such as: Crisis Intervention Services have two main components, maximum units and modifier requirements. SFY 2023 Hospital Provider Fee Memorandum - Posted 06/15/22. The policies below are in PDF format. check your deductible, change your <> Not already Contracted to Sell for CareSource? Background Speech language pathology services include the diagnosis and treatment of speech and language disorders. The Department of Community Health (DCH) administers Medicaid reimbursement and associated policy for mental health treatment and services through partnership with The Department of Behavioral Health and Developmental Disabilities (DBHDD). This area of the Billing and Reimbursement site provides information on the major aspects of Medicaid related to audiology and speech-language pathology services, including audiology and speech-language pathology requirements and information for school based professionals. Download the free version of Adobe Reader. InterQual is a nationally recognized evidence-based decision support tool. They are used to help identify whether health care services are correctly coded for reimbursement. Members: 800-498-2071 4 0 obj Twitter page for Georgia Medicaid; Linkedin page for Georgia Medicaid; YouTube page for Georgia Medicaid; How can we help? Provider Fee Payment. They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies. According to Georgia Medicaid guidelines, a brief emotional/behavioral assessment performed during a non-periodic screening visit for a patient less than 21 years of age must be reported with modifier EP (EPSDT program) and billed in Place of Service 99 (Other). In turn, the plan pays providers for all of the Medicaid services a beneficiary may require that are included in the plans contract with the state. Revised SFY 2023 Hospital Provider Fee Payment Schedule - Updated 11/15/22. How you know. Online Form. . Email Us. Appropriate Use and Safety Edits: Attachment A(PDF), Pharmacy Prior Authorization and Medical Necessity Criteria (PDF). All policies found in the Peach State Health PlanPayment Policy Manual apply with respect to Peach State Health Planmembers. Please enable it in order to use the full functionality of our website. PDF. According to Georgia Medicaid guidelines, enteral nutrition supplies and equipment must be reported with the purchase modifier NU (New equipment). If you have a question about a specific matter, you should contact a professional advisor directly. nursing services, nutrition services, occupational therapy, orthotic and prosthetic training, physical therapy and speech-language pathology. These reimbursement policies apply to our Georgia Medicaid plans. Additional information on available services and policy requirements can be obtained by visiting https://dbhdd.georgia.gov/community-provider-manuals. stream As Georgias Behavioral Health Authority, DBHDD provides services through a network of community providers. https://dbhdd.georgia.gov/community-provider-manuals, https://www.myamerigroup.com/ga/georgia-home.html, https://dbhdd.georgia.gov/access-services, Mental Health and Substance Use Disorder Parity. Therefore, when crisis intervention services are billed with modifier U1, U2, U3, U4 or U5 and modifier U6, U7 or GT are not also appended, the crisis intervention services (H2011) will be recommended for denial. Members have full access to the material and can also email us regarding any billing or compliance issue, please considerjoining todayif you need assistance. If the screening is missed, it may be performed during a catch-up visit using modifier EP and HA or UA. WellCare Health Plans is committed to continuously improving its claims review and payment processes. 2021 Medicaid Enhancements to Reimbursement Policies | Wellcare These rates are inclusive of 13.37% Growth, Joint Commission & AHCA quality incentives and audited 2018 GL/PL Insurance Costs. Fee Schedules - Georgia Wellcare uses cookies. Payments for claims may be subject to limitations and/or qualifications. Copyright CareSource 2023. Georgia Medicaid offers benefits on a Fee-for-Service (FFS) basis or through managed care plans. Reimbursement policies are designed to assist you when submitting claims to CareSource. Section 1902(a)(30)(A) of the Social Security Act requires that such payments be consistent with efficiency, economy, and quality of care, and are sufficient to provide access equivalent to the general population. It is our intent to make claim payment policies that are simple to understand and in alignment with State Medicaid Manuals. The American Speech-Language-Hearing Association (ASHA) developed this document to provide an analysis of the 2022 Medicare Physician Fee Schedule (MPFS), including comments on relevant policy changes, a list of Current Procedural Terminology (CPT American Medical Association) codes used by speech-language pathologists (SLPs) with their national Enrollment Forms Under the FFS model, Georgia pays providers directly for each covered service received by a Medicaid beneficiary. 455 0 obj <> endobj According to Georgia Medicaid guidelines, children's intervention services must be reported with modifier HA (Child/adolescent . An official website of the State of Georgia. After dialing 1-800-273-TALK (1-800-273-8255), the caller is routed to their nearest crisis center to receive immediate counseling and local mental health referrals. If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department. Acthar Gel) (PDF), Ribavirin (Copegus, Moderiba, Rebetol, Ribasphere) (PDF), Rifabutin (Mycobutin), Rifabutin/Omeprazole/Amoxicillin (Talicia) (PDF), Risperidone Long-Acting Injection (Risperdal Consta) (PDF), Rituximab (Rituxan), Rituxan/Hyaluronidase (Rituxan Hycela) (PDF), Sapropterin Dihydrochloride (Kuvan) (PDF), Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors (PDF), Sucroferric Oxyhydroxide (Velphoro) (PDF), Tezacaftor/Ivacaftor; Ivacaftor (Symdeko) (PDF), Timothy grass pollen allergen extract (Grastek) (PDF), Tobramycin (Bethkis, Kitabis Pak, TOBI, TOBI Podhaler) (PDF), Tofacitinib (Xeljanz, Xeljanz Poor girl.XR) (PDF), Topical Diclofenac (Solaraze, Flector) (PDF), Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase (PDF), Treprostinil (Orenitram, Remodulin, Tyvaso) (PDF), Triamcinolone ER Injection (Zilretta) (PDF), triptorelin pamoate (Trelstar, Triptodur) (PDF), Valproate Sodium for Intravenous Injection (Depacon) (PDF), vincristine sulfate liposome injection (Marqibo) (PDF), Voretigene neparvovec-rzyl (Luxturna) (PDF), Age Limit for Tazarotene (Tazorac, Arazlo) (PDF), Benzodiazepine Use in Pediatric Seizure Disorders (PDF), Buprenorphine-Naloxone (Bunavail, Cassipa, Suboxone, Zubsolv) (PDF), Dasabuvir Ombitasvir Paritaprevir Ritonavir (Viekira XR, Viekira Pak)(PDF), Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira XR, Viekira Pak) (PDF), Epinephrine Injection Device - Quantity Limit Override (PDF), Factor IX Complex Human (Bebulin, Profilnine) (PDF), Factor VIII/von Willebrand Factor Complex (Human - Alphanate, Humate-P, Wilate) (PDF), Human Growth Hormone (Somapacitan, Somatropin) (PDF), euprolide acetate (Eligard, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped) (PDF), Levofloxacin (Levaquin) in Pediatric Community Acquired Pneumonia(PDF), Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF), Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF), Pediatric Benzodiazepine Use in Chemotherapy Induced Nausea and Vomiting CINV(PDF), Psychotropic Medication Continuity of Care (COC)(PDF), Request for Medically Necessary Drug Not on the PDL (PDF), Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi) (PDF), Topical Steroid Use For Eosinophilic Esophagitis (PDF), Topical Tretinoin in Adult Acne Vulgaris (PDF), Hydroxyprogesterone Caproate (Makena) (PDF), Lost, Stolen, Spilled or Broken Medications(PDF), Maximum Allowable Cost (MAC) Requirement(PDF), Cost to Charge Adjustments on Clean ClaimReviews (PDF), Distinct Procedure Modifiers Policy (PDF), E&M Bundling with Labs and Radiology (PDF), E&M Services Billed with Treatment Room Revenue Codes (PDF), Hospital Visit Codes Billed with Labs (PDF), Leveling of Care: Evaluation and Management Overcoding (PDF), Leveling of Emergency Room Services (PDF), Modifier to Procedure Code Validation (PDF), Multiple Diagnostic Cardiovascular Procedure Payment Reduction (MDCR) (PDF), Multiple Procedure Reduction: Ophthalmology (PDF), Non-obstectrical Pelvic and Transvaginal Ultrasounds (PDF), Not Medically Necessary Inpatient Service (PDF), Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF), Problem Oriented Visits with Preventative Services (PDF), Problem Oriented Visits with Surgical Procedures (PDF), Unbundling Adjustments on Clean Claim Reviews (PDF), Leveling Professional Fees for Emergency Room Services (PDF), Multiple Procedure Payment Reduction: Therapeutic Services (PDF), Reporting the Global Maternity Package (PDF), Problem Oriented Visits with Preventative Services(PDF), Fluticasone/Vilanterol (Breo Ellipta) (PDF). Before sharing sensitive or personal information, make sure youre on an official state website. Local, state, and federal government websites often end in .gov. These services are provided by speech-language-pathologists PDF Georgia State Board of Speech-Language Pathology/Audiology DCH also administers Medicaid-reimbursed behavioral health services for children and eligible adults in Georgia through four (4) Care Management Organizations (CMOs). This change is estimated to increase E&D Waiver expenditures for SFY 2022 as follows: The Georgia General Assembly passed legislation to increase Elderly and Disabled Waiver rates by 10% effective July 1, 2021. Join us and watch your business grow. Additionally, monaural hearing aids, when billed, must be reported with modifier RT or LT and are limited to one unit per side in a three-year period. Each payment rule is sourced by a generally accepted coding principle. b. Georgia Medicaid Coverage of Therapy Services hbbd```b`` According to Georgia Medicaid guidelines, the insertion of an implantable contraceptive device and the implantable contraceptive reported as part of a Medicaid family planning program is limited to once in a three-year period. The NDC serves as a universal product identifier for drugs. Medical and Dental Fee Schedules | State Board of Workers' Compensation The American Speech-Language-Hearing Association (ASHA) is the national professional, scientific, and credentialing association for 228,000 members and affiliates who are audiologists; speech-language pathologists; speech, language, and hearing scientists; audiology and speech-language pathology support personnel; and students. NC Medicaid Contact Center According to Georgia Medicaid guidelines, the children's intervention services reported with certain modifiers are limited to the assigned units for that modifier or modifier combination that are included in the Policies and Procedures Manual for Children's Intervention Services. According to Georgia Medicaid guidelines, the telehealth originating site facility fee must be reported with modifier EP (EPSDT program) and modifier GT (Via interactive audio or video telecommunication systems) when billed in a school setting. Speech Therapy and Audiology Fee Schedule - Jan. 5, 2022 - PDF. Speech Therapy and Audiology Fee Schedule - Jan. 5, 2022 - PDF. Web form outage is expected around 5:30pm on April 28, 2023. The Department also received approval for quality incentives related to the Joint Commission and American Health Care Association (AHCA) Accreditation effective August 14, 2020. In general, Georgia set provider payments under fee-for-service. reimbursement rate is 85.6% of costs. Georgia Families Medicaid; Georgia Families PeachCare for Kids . You do not have JavaScript Enabled on this browser. Required Documentation to enroll with Georgia Medicaid: PDF: 468.3: 06/20/2019 : Step By Step . FY 2021 revised rates inclusive of 18.37% Growth and Quality Incentive Please note that the reimbursement rate sheets (R-32) are in alphabetical order. endobj The information that has been accurate previously can be particularly dependent on changes in time or circumstances. Therefore, enteral nutrition supplies are recommended for denial when billed without modifier NU. 4a, Col 004, lines 002,005,006,008,009,015: 37) According to Georgia Medicaid guidelines, as part of the EPSDT program, an inter-periodic hearing screening and a periodic preventive service for patients less than 21 years of age should not be reported on the same day. 1 0 obj Under managed care, Georgia pays a fee to a managed care plan for each person enrolled in the plan. Family Planning Services have two main components, frequency limitations and modifier requirements. Local, state, and federal government websites often end in .gov. An official website of the State of Georgia. You will need Adobe Reader to open PDFs on this site. An official website of the State of Georgia. Peach State Health Plan utilizes InterQualcriteria for those medical technologies, procedures or pharmaceutical treatments for which a Peach State Health Planclinical policy does not exist. The Children's Intervention Services (CIS) Program provides coverage for restorative and rehabilitative services including audiology, health and behavior assessments, nursing services, nutrition services, occupational therapy, orthotic and prosthetic training, physical therapy and speech-language pathology. Board of Speech Pathology and Audiology | Georgia Secretary of State (ga.gov) Fee Schedule (*All fees include a $10 mail in application processing fee) *Application for Speech Language Pathologist or Audiologist by Examination, ASHA, or Endorsement $ 120.00 *Application for PCE or RPE $ 40.00 *Application for Speech Aide $ 50.00 They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance. Behavioral Health Services | Georgia Medicaid Learn moreabout how we provide comprehensive support for members. Use the portal to pay your premium, endobj Authorization for Cancer Treatment/New Century Health, 25-Hydroxyvitamin D Testing in Children and Adolescents (PDF), Allogeneic Hematopoietic Cell Transplants for Sickle Cell(PDF), Ambulatory Surgery Center Optimization (PDF), Cosmetic and Reconstructive Surgery (PDF), Diaphragmatic/Phrenic Nerve Stimulation (PDF), Drugs of Abuse: Definitive Testing (PDF), Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF), Genetic Testing Aortopathies and Connective Tissue Disorder (PDF), Genetic Testing Dermatologic Conditions (PDF), Genetic Testing Epilepsy Neurodegenerative Neuromuscular Disorder (PDF), Genetic Testing Exome and Genome Sequencing for the Diagnosis of Genetic Disorders (PDF), Genetic Testing Gastroenterologic Disorders (non-cancerous) (PDF), Genetic Testing General Approach to Genetic Testing (PDF), Genetic Testing Hematologic Conditions (non-cancerous) (PDF), Genetic Testing Hereditary Cancer Susceptibility (PDF), Genetic Testing Immune Autoimmune and Rheumatoid Disorders (PDF), Genetic Testing Metabolic Endocrine and Mitochondrial Disorders(PDF), Genetic Testing Multisystem Inherited Disorders, Intellectual Disability and Developmental Delay(PDF), Genetic Testing Non-Invasive Prenatal Screening (NIPS)(PDF), Genetic Testing Preimplantation Genetic Testing(PDF), Genetic Testing Prenatal and Precon Carrier Screening(PDF), Genetic Testing Prenatal Diagnosis (via Amnio CVS or PUBS) and Pregnancy Loss(PDF), Genetic Testing Skeletal Dysplasia and Rare Bone Disorders(PDF), Helicobacter Pylori Serology Testing (PDF), Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF), Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF), Infant Apnea Monitors Clinical Policy (PDF), Intestinal and Multivisceral Transplant (PDF), Intradiscal Steroid Injections for Pain Management(PDF), IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures(PDF), Low-Frequency Ultrasound Therapy for Wound Management (PDF), Measurement of Serum 1,25-dihydroxyvitamin D (PDF), Neonatal Abstinence Syndrome Guidelines (PDF), Nerve Blocksand Neurolysis for Pain Management (PDF), Neuromuscular Electrical Stimulation (PDF), Nonmyeloablative Allogeneic Stem Cell Transplants (PDF), Oncology Circulating Tumor DNA and Circulating Tumor Cells (PDF), Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF), Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF), Phototherapy for Neonatal Hyperbilirubinemia(PDF), Physical, Occupational, and Speech Therapy Services (PDF), Physical, Occupational, Speech, and Feeding Therapy (PDF), Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF), Reduction Mammoplasty and Gynecomastia Surgery (PDF), Sacroiliac Joint Interventions for Pain Management (PDF), Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins(PDF), Selective Dorsal Rhizotomy for Spasticity in Cerebral Palsy (PDF), Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF), Skin Substitutes for Chronic Wounds (PDF), Spinal Cord, Peripheral Nerve, and Percutaneous Electrical Nerve Stimulation (PDF), Stereotactic Body Radiation Therapy (PDF), Testing for Select Genitourinary Conditions (PDF), Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF), Transcather Closer of Patent Foramen Ovale (PDF), Transplant Service Documentation Requirements, Trigger Point Injections for Pain Management (PDF), Urinary Incontinence Devices and Treatments (PDF), IV Moderate Sedation, IV Deep Sedation, and General Anesthesia for Dental Procedures (PDF), Non-myeloablative Allogeneic Stem Cell Transplants (PDF), Physical, Occupation, and Speech Therapy Services, Sclerotherapy and chemical endovenous ablation for Varicose Veins(PDF), Transcatheter Closure of Patent Foramen Ovale (PDF), Behavioral Health Treatment Document Requirement(PDF), Deep Transcranial Magnetic Stimulation for Obsessive Compulsive Disorder (PDF), Substance Use Disorder Treatment and Services (PDF), Biofeedback for Behavioral Health Disorders (PDF), Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (PDF), Adjacent Tissue Transfer Grafts involving Eyelid (PDF), Anterior Segment Photography with FA (PDF), Blepharoplasty, Ptosis and Canthoplasty (PDF), Dark Adaptation and Color Vision Examinations (92283/92284) (PDF), Destruction of a Localized Lesion of the Retina (PDF), Destruction of Localized Lesion of Choroid (PDF), Examination Guidelines for Diabetic Patients (PDF), Indocyanine Green (ICG) Angiography (PDF), Infracture of the Inferior Turbinate (PDF), Laser Iridotomy and Iridectomy for Glaucoma (PDF), Photodynamic and Intravitreal Therapies and Pharmaceuticals (PDF), Probing and Closure of the Lacrimal Duct System (PDF), Surgical Excision of Eyelid Lesions (PDF), Teleretinal Screening for Diabetic Retinopathy (PDF), Ado-Trastuzumab Emtansine (Kadcyla) (PDF), Age Limit Override (Codeine, Tramadol, Hydrocodone) (PDF), Alendronate (Binosto, Fosamax plus D) (PDF), Alpha-1 Proteinase Inhibitors (Aralast NP, Glassia, Prolastin-C, Zemaira) (PDF), Antithymocyte Globulin (Thymoglobulin, Atgam) (PDF), Anti-Inhibitor Coagulant Complex, Human (Feiba) (PDF), Aprepitant (Emend, Cinvanti), Fosaprepitant (Emend for injection) (PDF), Aripiprazole Long-Acting Injections (Abilify Maintena, Aristada) (PDF), Baclofen (Gablofen, Lioresal, Ozobax) (PDF), Bevacizumab (Avastin, Mvasi, Zirabev) (PDF), Blocking Adjudication of Controlled Substance Prescriptions for Selected Prescribers(PDF), Brand Name Override and Non-Formulary Medications (PDF), Brexucabtagene Autoleucel (Tecartus)(PDF), Brinzolamide/Brimonidine (Simbrinza) (PDF), Budesonide Suspension (Pulmicort Respules) (PDF), Buprenorphine Implant/Injection (Probuphine, Sublocade) (PDF), Buprenorphine-Naloxone (Bunavail, Cassipa, Suboxone) (PDF), C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda) (PDF), C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest) (PDF), Cabozantinib (Cometriq, Cabometyx) (PDF), Ciprofloxacin-Dexamethasone (Ciprodex) (PDF), Ciprofloxacin/Fluocinolone (Otovel) (PDF), Clindamycin Phosphate/Benzoyl Peroxide (BenzaClin) (PDF), Clinical Pharmacy Services Inter-rater Reliability (PDF), Conjugated Estrogens/Bazedoxifene (Duavee) (PDF), Corticosteroid Intravitreal Implants (Iluvien, Ozurdex, Retisert, Yutiq) (PDF), Cysteamine oral (Cystagon, Procysbi) (PDF), Cytomegalovirus Immune Globulin (Cytogam)(PDF), Desmopressin Acetate (DDAVP, Stimate, Noctiva) (PDF), Dextromethorphan-Quinidine (Nuedexta) (PDF), Dimethyl Fumarate (Tecfidera), Diroximel Fumarate (Vumerity) (PDF), Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (PDF), Doxepin (Silenor, Prudoxin, Zonalon) (PDF), Doxycycline Hyclate (Acticlate, Doryx), Doxycycline (Oracea) (PDF), Early and Periodic Screening, Diagnostic, and Treatment Benefit for Pediatric Members (PDF), Elexacaftor/Ivacaftor/Tezacaftor; Ivacaftor (Trikafta) (PDF), Emtricitabine/Tenofovir Alafenamide (Descovy)(PDF), Everolimus (Afinitor, Afinitor Disperz, Zortress) (PDF), Factor IX Complex, Human (Profilnine) (PDF), Factor VIIa, Recombinant (NovoSeven RT) (PDF), Factor VIIa, Recombinant (NovoSeven RT, SevenFact) (PDF), Factor XIII A-Subunit, Recombinant (Tretten) (PDF), Fam-trastuzumab Deruxtecan-nxki (Enhertu) (PDF), Fentanyl IR (Abstral, Actiq, Fentora, Lazanda, Subsys) (PDF), Filagrastim (Neupogen), Filagrastim-sndz (Zarxio), Tbo-filagrastim (Granix) (PDF), Formulary Medications without Specific Guidelines (PDF), Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (PDF), Granisetron (Kytril, Sancuso, Sustol) (PDF), histrelin acetate (Vantas, Supprelin LA) (PDF), Hydroxyprogesterone Caproate (Makena/compound), Indacaterol/Glycopyrrolate (Utibron Neohaler) (PDF), Infertility and Fertility Preservation (PDF), Infliximab (Remicade, Inflectra, Renflexis) (PDF), Insulin Delivery Systems (V-Go, OmniPod, InPen) (PDF), Interferon beta-1b (Betaseron, Extavia) (PDF), Intrathecal Baclofen (Gablofen, Lioresal) (PDF), Isotretinoin (Absorica, Absorica LD, Amnesteem, Claravis, Myorisan, Zenatane) (PDF), Itraconazole (Sporanox, Onmel, Tolsura) (PDF), Lesinurad (Zurampic), Lesinurad/Allopurinol (Duzallo) (PDF), leuprolide acetate (Eligard, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped) (PDF), Levalbuterol (Xopenex HFA/Inhalation Solution) (PDF), Lidocaine Transdermal (Lidoderm, ZTlido) (PDF), Lutetium Lu 177 Dotatate (Lutathera)(PDF), Montelukast oral granules (Singulair) (PDF), Methotrexate (Otrexup, Rasuvo, Xatmep, Reditrex) (PDF), Methoxy polyethylene glycol-epoetin beta (Mircera) (PDF, Methylnaltrexone Bromide (Relistor) (PDF), Minocycline ER (Solodyn, Ximino, Minolira) and Microspheres (Arestin) (PDF), Moxetumomab pasudotox-tdfk (Lumoxiti) (PDF), Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF), Nadofaragene Firadenovec (Instiladrin) (PDF), Naproxen oral suspension (Naprosyn) (PDF), Neomycin/Fluocinolone Cream (Neo-Synalar)_(PDF), Netarsudil (Rhopressa), Netarsudil/Latanoprost (Rocklatan) (PDF), Netupitant and Palonosetron (Akynzeo), Fosnetupitant and Palonosetron (Akynzeo IV) (PDF), No Coverage Criteria/Off-Label Use Policy (PDF), Non-Formulary and Formulary Contraceptives (PDF), Octreotide (Sandostatin, Sandostatin LAR) (PDF), Octreotide Acetate (Sandostatin, Sandostatin LAR Depot, Bynfezia) (PDF), Olanzapine Long-Acting Injection (Zyprexa Relprevv)(PDF), Onasemnogene Abeparvovec (Zolgensma) (PDF), Paclitaxel, Protein-Bound (Abraxane) (PDF), Peanut Allergen Powder-dnfp (Palforzia) (PDF), Pegaspargase (Oncaspar), Calaspargase pegol-mknl (Asparlas) (PDF), peginterferon alfa-2b (PegIntron, Sylatron) (PDF), Pharmacy and Therapeutics Committee(PDF), Pharmacy Prior Authorization and Medical Necessity Criteria(PDF), Potassium Chloride for Oral Solution (Klor-Con Powder) (PDF), Propranolol HCl Oral Solution (Hemangeol) (PDF), Protein C Concentrate, Human (Ceprotin) (PDF), Repository Corticotropin Injection (H.P.