Hospital Inpatient. Physician Expenditures (IPDSF04X - IPDOT04X, IPDTC04X, IPDXP04X) Separately billing doctor (SBD) expenses typically cover services provided to patients in hospital settings by providers like anesthesiologists, radiologists, and pathologists, whose charges are often not included in hospital bills. For medical doctors who bill separately (i.e., outside the hospital bill), a separate data collection effort within the Medical Provider Component was performed to obtain this same set of expenditure information from each separately billing doctor. It should be noted that there could be several separately billing doctors associated with a medical event. For example, a hospital inpatient stay could have a radiologist, anesthesiologist, pathologist and a surgeon associated with it. If their services are not included in the hospital bill then this is one medical event with four separately billing doctors. The imputed expenditure information associated with the separately billing doctors for a hospital inpatient stay is combined (i.e., the expenditures incurred by the radiologist + anesthesiologist + pathologist + surgeon) and is provided on the file. IPDSF04X - IPDOT04X are the 12 sources of payment; IPDXP04X is the sum of the 12 sources of payments; and IPDTC04X is the physician’s total charge. Data users/analysts need to take into consideration whether to analyze facility and SBD expenditures separately, combine them within service categories, or collapse them across service categories (e.g., combine SBD expenditures with expenditures for physician visits to offices and/or outpatient departments).
Hospital Inpatient. No charge; Member pays nothing Non-Emergency inpatient hospital services require Preauthorization. Hospital - Outpatient: No charge; Member pays nothing Outpatient Services: No charge; Member pays nothing Exclusions: Birthing tubs; genetic testing of non-Members; fetal ultrasound in the absence of medical indications Mental Health Mental health services provided at the most clinically appropriate and Medically Necessary level of mental health care intervention as determined by KFHPWA’s medical director. Treatment may utilize psychiatric, psychological and/or psychotherapy services to achieve these objectives. Mental health services including medical management and prescriptions are covered the same as for any other condition. Behavioral treatment for a DSM category diagnosis. Eating disorder treatment provided on an inpatient or outpatient basis must be Medically Necessary and the treatment program must meet clinical criteria standards. The inpatient mental health benefit can only be used if a Member with an eating disorder also meets clinical criteria for inpatient psychiatric care. Applied behavioral analysis (ABA) therapy, limited to outpatient treatment of an autism spectrum disorder as diagnosed and prescribed by a neurologist, pediatric neurologist, developmental pediatrician, psychologist or psychiatrist experienced in the diagnosis and treatment of autism. Documented diagnostic assessments, individualized treatment plans and progress evaluations are required. Partial hospitalization is covered subject to Hospital - Outpatient Cost Shares. Services for any involuntary court-ordered treatment program shall be covered only if determined to be Medically Necessary by KFHPWA’s medical director. Services provided under involuntary commitment statutes are covered. Coverage for voluntary/involuntary Emergency inpatient Hospital - Inpatient: After Deductible, Member pays 10% Plan Coinsurance Hospital - Outpatient: After Deductible, Member pays 10% Plan Coinsurance Outpatient Services: Office visits: After Deductible, Member pays $10 Copayment for primary care provider or specialty care provider office visits Deductible does not apply to first 4 office visits per calendar year All other services, including surgical services: After Deductible, Member pays 10% Plan Coinsurance Group Sessions: No charge; Member pays nothing psychiatric services is subject to the Emergency services benefit. Members must notify KFHPWA by way of the Hospital notification line withi...
Hospital Inpatient. Plan will pay Provider at the then current Indiana Medicaid rates and methodology, less applicable Copayments.
Hospital Inpatient. Projected PMPM and Actual PMPM shall include all claims costs for hospital inpatient facilities except those for mental health, substance abuse, maternity, and ITS claims, and excluding professional fees. Any other inclusions or exclusions will be prospectively agreed upon by the parties.
