Page 49 - Aegion PPO SPDs
P. 49
Post-service Review – A review of a service, treatment or admission for a benefit coverage that is
conducted after the service has been provided. Post-service reviews are performed when a service,
treatment or admission did not need a Precertification, or when a needed Precertification was not
obtained. Post-service reviews are done for a service, treatment or admission in which the Claims
Administrator has a related clinical coverage guideline and are typically initiated by the Claims
Administrator.
IMPORTANT NOTE: IF YOU OR YOUR NON NETWORK PROVIDER DO NOT OBTAIN THE REQUIRED
PRECERTIFICATION, A $300 PENALTY WILL APPLY AND THE PLAN’S REIMBURSEMENT WILL BE
REDUCED. THIS DOES NOT APPLY TO MEDICALLY NECESSARY SERVICES FROM A NETWORK
OR BLUECARD PROVIDER.
Inpatient Admission:
Inclusive of all Acute Inpatient, Skilled Nursing Facility, Long Term Acute Rehab, and OB delivery stays
beyond the Federal Mandate minimum LOS (including newborn stays beyond the mother’s stay)
Emergency Admissions (Requires Plan notification no later than 2 business days after admission
Outpatient and Surgical Services:
Air Ambulance (excludes 911 initiated emergency transport)
Bone-Anchored and Bone Conduction Hearing Aids
Cochlear Implants and Auditory Brainstem Implants
Corneal Collagen Cross-Linking
Cryopreservation of Oocytes or Ovarian Tissue
Diaphragmatic/Phrenic Nerve Stimulation pacing systems
Deep Brain, Cortical, and Cerebellar Stimulation
Electric Tumor Treatment Field (TTF) for treatment of glioblastoma
Immunoprophylaxis for respiratory syncytial virus (RSV)
Implantable Middle Ear Hearing Aids
Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
Keratoprosthesis
MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
Occipital nerve stimulation
Percutaneous Neurolysis for Chronic Neck and Back Pain
Photocoagulation of Macular Drusen
Private Duty Nursing
Presbyopia and Stigmatism – Correcting Intraocular Lenses
Radiofrequency Ablation to Treat Tumors Outside the Liver
Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia
Treatment of Hyperhidrosis
Treatments for Urinary Incontinence
Transcatheter Uterine Artery Embolization
Treatment of Temporomandibular Disorders
Vagus Nerve Stimulation
Diagnostic Testing:
Cardiac Ion Channel Genetic Testing
49
conducted after the service has been provided. Post-service reviews are performed when a service,
treatment or admission did not need a Precertification, or when a needed Precertification was not
obtained. Post-service reviews are done for a service, treatment or admission in which the Claims
Administrator has a related clinical coverage guideline and are typically initiated by the Claims
Administrator.
IMPORTANT NOTE: IF YOU OR YOUR NON NETWORK PROVIDER DO NOT OBTAIN THE REQUIRED
PRECERTIFICATION, A $300 PENALTY WILL APPLY AND THE PLAN’S REIMBURSEMENT WILL BE
REDUCED. THIS DOES NOT APPLY TO MEDICALLY NECESSARY SERVICES FROM A NETWORK
OR BLUECARD PROVIDER.
Inpatient Admission:
Inclusive of all Acute Inpatient, Skilled Nursing Facility, Long Term Acute Rehab, and OB delivery stays
beyond the Federal Mandate minimum LOS (including newborn stays beyond the mother’s stay)
Emergency Admissions (Requires Plan notification no later than 2 business days after admission
Outpatient and Surgical Services:
Air Ambulance (excludes 911 initiated emergency transport)
Bone-Anchored and Bone Conduction Hearing Aids
Cochlear Implants and Auditory Brainstem Implants
Corneal Collagen Cross-Linking
Cryopreservation of Oocytes or Ovarian Tissue
Diaphragmatic/Phrenic Nerve Stimulation pacing systems
Deep Brain, Cortical, and Cerebellar Stimulation
Electric Tumor Treatment Field (TTF) for treatment of glioblastoma
Immunoprophylaxis for respiratory syncytial virus (RSV)
Implantable Middle Ear Hearing Aids
Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
Keratoprosthesis
MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
Occipital nerve stimulation
Percutaneous Neurolysis for Chronic Neck and Back Pain
Photocoagulation of Macular Drusen
Private Duty Nursing
Presbyopia and Stigmatism – Correcting Intraocular Lenses
Radiofrequency Ablation to Treat Tumors Outside the Liver
Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia
Treatment of Hyperhidrosis
Treatments for Urinary Incontinence
Transcatheter Uterine Artery Embolization
Treatment of Temporomandibular Disorders
Vagus Nerve Stimulation
Diagnostic Testing:
Cardiac Ion Channel Genetic Testing
49
