Page 61 - Aegion Value Plan SPDs
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Prior Approval and Precertification
In order to maximize Your benefits, the Claims Administrator strongly encourages You to call its’ 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 The Claims Administrator will assist
You in maximizing Your benefits by providing coverage information, including details regarding what is
covered and whether any clinical coverage guidelines, medical policies, Network Transplant Provider
requirements, or exclusions are applicable. Contact the Member Services telephone number on the back
of Your Identification Card and ask for the transplant coordinator. Even if the Claims Administrator
issues a prior approval for the Covered Transplant Procedure, You or Your Provider must call the Claims
Administrator’s Transplant Department for precertification prior to the transplant whether this is performed
in an Inpatient or Outpatient setting.
Please note that there are instances where Your Provider requests approval for Human Leukocyte Antigen
(HLA) testing, donor searches and/or a collection and storage of stem cells prior to the final determination
as to what transplant procedure will be requested. Under these circumstances, the HLA testing and donor
search charges are covered as routine diagnostic testing. The collection and storage request will be
reviewed for Medical Necessity and may be approved. However, such an approval for HLA testing, donor
search and/or a collection and storage is NOT an approval for the subsequent requested transplant. A
separate Medical Necessity determination will be made for the transplant procedure.
Transportation and Lodging
The Plan will provide assistance with reasonable and necessary travel expenses as determined by the
Claims Administrator when You obtain prior approval and are required to travel more than 75 miles from
Your residence to reach the facility where Your Covered Transplant Procedure will be performed. The
Plan's assistance with travel expenses includes transportation to and from the facility and lodging for the
patient and one companion. If the Member receiving treatment is a minor, then reasonable and necessary
expenses for transportation and lodging may be allowed for two companions. The Member must submit
itemized receipts for transportation and lodging expenses in a form satisfactory to the Claims Administrator
when claims are filed. Contact the Claims Administrator for detailed information.
“Travel” is defined to mean Lodging and Transportation (“MTL”). “Round Trip” is defined to mean the
following:
1. Lodging incurred en route to and from the medical care facility.
2. Mileage greater than 75 miles from the member’s/recipient’s permanent residence to an
approved medical care facility, and
3. Mileage from an approved medical care facility to the member’s/recipient’s permanent
residence. It does not include the mileage in between the time the member/recipient arrives at
the medical care facility and the time the member/recipient departs from the medical care facility.
Medical Supplies, Durable Medical Equipment, and Appliances
The supplies, equipment and appliances described below are Covered Services under this benefit.
Supplies, equipment and appliances that include comfort, luxury, or convenience items or features that
exceed what is Medically Necessary in Your situation will not be covered. Reimbursement will be based
on the Maximum Allowed Amount for a standard item that is a Covered Service, serves the same purpose,
and is Medically Necessary. Any expense that exceeds the Maximum Allowed Amount for the standard
item which is a Covered Service is Your responsibility.
Covered Services include, but are not limited to:
Medical and surgical supplies - Syringes, needles, oxygen, surgical dressings, splints and other
similar items which serve only a medical purpose. Covered Services do not include items usually
stocked in the home for general use like Band-Aids, thermometers, and petroleum jelly. Prescription
drugs and biologicals that cannot be self administered and are provided in a Physician’s office, including
but not limited to, Depo-Provera.
61
In order to maximize Your benefits, the Claims Administrator strongly encourages You to call its’ 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 The Claims Administrator will assist
You in maximizing Your benefits by providing coverage information, including details regarding what is
covered and whether any clinical coverage guidelines, medical policies, Network Transplant Provider
requirements, or exclusions are applicable. Contact the Member Services telephone number on the back
of Your Identification Card and ask for the transplant coordinator. Even if the Claims Administrator
issues a prior approval for the Covered Transplant Procedure, You or Your Provider must call the Claims
Administrator’s Transplant Department for precertification prior to the transplant whether this is performed
in an Inpatient or Outpatient setting.
Please note that there are instances where Your Provider requests approval for Human Leukocyte Antigen
(HLA) testing, donor searches and/or a collection and storage of stem cells prior to the final determination
as to what transplant procedure will be requested. Under these circumstances, the HLA testing and donor
search charges are covered as routine diagnostic testing. The collection and storage request will be
reviewed for Medical Necessity and may be approved. However, such an approval for HLA testing, donor
search and/or a collection and storage is NOT an approval for the subsequent requested transplant. A
separate Medical Necessity determination will be made for the transplant procedure.
Transportation and Lodging
The Plan will provide assistance with reasonable and necessary travel expenses as determined by the
Claims Administrator when You obtain prior approval and are required to travel more than 75 miles from
Your residence to reach the facility where Your Covered Transplant Procedure will be performed. The
Plan's assistance with travel expenses includes transportation to and from the facility and lodging for the
patient and one companion. If the Member receiving treatment is a minor, then reasonable and necessary
expenses for transportation and lodging may be allowed for two companions. The Member must submit
itemized receipts for transportation and lodging expenses in a form satisfactory to the Claims Administrator
when claims are filed. Contact the Claims Administrator for detailed information.
“Travel” is defined to mean Lodging and Transportation (“MTL”). “Round Trip” is defined to mean the
following:
1. Lodging incurred en route to and from the medical care facility.
2. Mileage greater than 75 miles from the member’s/recipient’s permanent residence to an
approved medical care facility, and
3. Mileage from an approved medical care facility to the member’s/recipient’s permanent
residence. It does not include the mileage in between the time the member/recipient arrives at
the medical care facility and the time the member/recipient departs from the medical care facility.
Medical Supplies, Durable Medical Equipment, and Appliances
The supplies, equipment and appliances described below are Covered Services under this benefit.
Supplies, equipment and appliances that include comfort, luxury, or convenience items or features that
exceed what is Medically Necessary in Your situation will not be covered. Reimbursement will be based
on the Maximum Allowed Amount for a standard item that is a Covered Service, serves the same purpose,
and is Medically Necessary. Any expense that exceeds the Maximum Allowed Amount for the standard
item which is a Covered Service is Your responsibility.
Covered Services include, but are not limited to:
Medical and surgical supplies - Syringes, needles, oxygen, surgical dressings, splints and other
similar items which serve only a medical purpose. Covered Services do not include items usually
stocked in the home for general use like Band-Aids, thermometers, and petroleum jelly. Prescription
drugs and biologicals that cannot be self administered and are provided in a Physician’s office, including
but not limited to, Depo-Provera.
61
