Page 60 - Aegion Value Plan SPDs
P. 60
Physical therapy, occupational therapy, speech therapy, and respiratory therapy given by a licensed
therapist.
Pharmaceuticals, medical equipment, and supplies needed for the palliative care of Your condition,
including oxygen and related respiratory therapy supplies.
Bereavement (grief) services, including a review of the needs of the bereaved family and the
development of a care plan to meet those needs, both before and after the Member’s death.
Bereavement services are available to surviving Members of the immediate family for one year after
the Member’s death. Immediate family means Your spouse, children, stepchildren, parents, brothers
and sisters.
Your Doctor and Hospice medical director must certify that You are terminally ill and likely have less than
12 months to live. Your Doctor must agree to care by the Hospice and must be consulted in the development
of the care plan. The Hospice must keep a written care plan on file and give it to the Claims Administrator
upon request.
Benefits for services beyond those listed above that are given for disease modification or palliation, such
as but not limited to, chemotherapy and radiation therapy, are available to a Member in Hospice. These
services are covered under other parts of this Benefit Booklet.
Human Organ and Tissue Transplant Services
For cornea and kidney transplants, the transplant and tissue services benefits or requirements described below do
not apply. These services are paid as Inpatient Services, Outpatient Services or Physician Office Services
depending where the service is performed.
Covered Transplant Procedure
Any Medically Necessary human organ and tissue transplant as determined by the Claims Administrator
including necessary acquisition costs and preparatory myeloblative therapy.
Covered Transplant Services – All Covered Transplant Procedures and all Covered Services directly
related to the disease that has necessitated the Covered Transplant Procedure or that arises as a result of
the Covered Transplant Procedure within a Covered Transplant Benefit Period, including any diagnostic
evaluation for the purpose of determining a Member’s appropriateness for a Covered Transplant Procedure.
Notification
To maximize Your benefits, You need to call the Claims Administrator's transplant department to
discuss benefit coverage when it is determined a transplant may be needed. You must do this before
You have an evaluation and/or work-up for a transplant. Your evaluation and work-up services must
be provided by a Network Transplant Provider to receive the maximum benefits.
Contact the Member Services telephone number on the back of Your Identification Card and ask for the
transplant coordinator. The Claims Administrator will then assist the Member in maximizing their benefits
by providing coverage information including details regarding what is covered and whether any Medical
Policies, network requirements or Benefit Booklet exclusions are applicable. Failure to obtain this
information prior to receiving services could result in increased financial responsibility for the Member.
Covered Transplant Benefit Period
At a Network Transplant Provider Facility, the Transplant Benefit Period starts one day before a Covered
Transplant Procedure and lasts for the applicable case rate/global time period. The number of days will
vary depending on the type of transplant received and the Network Transplant Provider agreement. Call
the Claims Administrator for specific Network Transplant Provider details for services received at or
coordinated by a Network Transplant Provider Facility.
At an Out-of-Network Transplant Provider Facility, the Transplant Benefit Period starts one day before a
Covered Transplant Procedure and lasts until the date of discharge.
60
therapist.
Pharmaceuticals, medical equipment, and supplies needed for the palliative care of Your condition,
including oxygen and related respiratory therapy supplies.
Bereavement (grief) services, including a review of the needs of the bereaved family and the
development of a care plan to meet those needs, both before and after the Member’s death.
Bereavement services are available to surviving Members of the immediate family for one year after
the Member’s death. Immediate family means Your spouse, children, stepchildren, parents, brothers
and sisters.
Your Doctor and Hospice medical director must certify that You are terminally ill and likely have less than
12 months to live. Your Doctor must agree to care by the Hospice and must be consulted in the development
of the care plan. The Hospice must keep a written care plan on file and give it to the Claims Administrator
upon request.
Benefits for services beyond those listed above that are given for disease modification or palliation, such
as but not limited to, chemotherapy and radiation therapy, are available to a Member in Hospice. These
services are covered under other parts of this Benefit Booklet.
Human Organ and Tissue Transplant Services
For cornea and kidney transplants, the transplant and tissue services benefits or requirements described below do
not apply. These services are paid as Inpatient Services, Outpatient Services or Physician Office Services
depending where the service is performed.
Covered Transplant Procedure
Any Medically Necessary human organ and tissue transplant as determined by the Claims Administrator
including necessary acquisition costs and preparatory myeloblative therapy.
Covered Transplant Services – All Covered Transplant Procedures and all Covered Services directly
related to the disease that has necessitated the Covered Transplant Procedure or that arises as a result of
the Covered Transplant Procedure within a Covered Transplant Benefit Period, including any diagnostic
evaluation for the purpose of determining a Member’s appropriateness for a Covered Transplant Procedure.
Notification
To maximize Your benefits, You need to call the Claims Administrator's transplant department to
discuss benefit coverage when it is determined a transplant may be needed. You must do this before
You have an evaluation and/or work-up for a transplant. Your evaluation and work-up services must
be provided by a Network Transplant Provider to receive the maximum benefits.
Contact the Member Services telephone number on the back of Your Identification Card and ask for the
transplant coordinator. The Claims Administrator will then assist the Member in maximizing their benefits
by providing coverage information including details regarding what is covered and whether any Medical
Policies, network requirements or Benefit Booklet exclusions are applicable. Failure to obtain this
information prior to receiving services could result in increased financial responsibility for the Member.
Covered Transplant Benefit Period
At a Network Transplant Provider Facility, the Transplant Benefit Period starts one day before a Covered
Transplant Procedure and lasts for the applicable case rate/global time period. The number of days will
vary depending on the type of transplant received and the Network Transplant Provider agreement. Call
the Claims Administrator for specific Network Transplant Provider details for services received at or
coordinated by a Network Transplant Provider Facility.
At an Out-of-Network Transplant Provider Facility, the Transplant Benefit Period starts one day before a
Covered Transplant Procedure and lasts until the date of discharge.
60
