Medical and Surgical Services. A. Physician’s services at the:
Medical and Surgical Services. The Contractor shall determine the medical necessity for emergency and non- emergency inpatient hospital admission prior authorizations, continued stays, Retroactive Eligibility Reviews and Retrospective Reviews for inpatient medical/surgical services to eligible Mississippi Medicaid beneficiaries utilizing the Division’s approved criteria and policies.
Medical and Surgical Services. 7.5.6.1 The Contractor shall make available through its Network Providers the following Medical and Surgical Services:
Medical and Surgical Services. The Contractor shall provide the following medical and surgical services as Covered Services: Early and Periodic Screening, Diagnostic and Treatment (“EPSDT”) services, as defined in Section 1905(r) of the Social Security Act; Primary Care Physician visits, including nursing services; Specialist treatment, once referred by the selected PCP if outside of the Enrollee’s PPN; Sub-specialist treatment, once referred by the selected PCP if outside of the Enrollee’s PPN; Physician home visits when Medically Necessary; Respiratory therapy, without limitations; Anesthesia services (except for epidural anesthesia); Radiology services; Pathology services; Surgery; Outpatient surgery facility services; Nursing services; Voluntary sterilization of men and women of legal age and sound mind, provided that they have been previously informed about the medical procedure’s implications, and that there is evidence of Enrollee’s written consent by completing the Sterilization Consent Form included as Attachment 22 to this Contract; Prosthetics, including the supply of all extremities of the human body including therapeutic ocular prosthetics, segmental instrument tray, and spine fusion in scoliosis and vertebral surgery; Ostomy equipment for outpatient-level ostomized patients; Transfusion of blood and blood plasma services, without limitations, including the following: Antihemophilic recombinant factor VIII; Antihemophilic recombinant factor IX; Anti-inhibitor coagulant complex (Feiba); and Antihemophilic factor VIII, human/Von Willebrand factor complex. Services to patients with Level 1 or Level 2 of chronic renal disease (Levels 3 to 5 are included in Special Coverage in Section 7.7). Chronic renal disease Levels 1 and 2 are defined as follows:
Medical and Surgical Services. 7.5.6.1 The Contractor shall provide the following Medical and Surgical Services:
Medical and Surgical Services. Routine Adult Physical Exam $10 co-payment 20% of plan allowance Well-child care $10 Plan pays 80% of plan allowance Cancer screening – mammogram, prostate screening and PAP tests No charge Plan pays 80% of plan allowance Non-routine office visit $10 co-payment 20% of plan allowance Allergy shots $10 co-payment 20% of plan allowance Maternity care $10 1st visit only 20% of plan allowance Surgery, laboratory test X-rays No charge 20% of plan allowance Hospital Services (Semi-private room) Inpatient Medical • Facility • Physician No charge No charge 20% of plan allowance 20% of plan allowance Out patient Medical • Facility No charge No charge • Physician No charge No charge • Emergency Room $35 $35 Mental Health Care Inpatient services (limited to 45 days per calendar year) • Facility • Physician No charge No charge 20% of plan allowance 20% of plan allowance Outpatient services (per calendar year) • Visits 1-40 • Visits 41- 20% of plan allowance 20% of plan allowance 20% of plan allowance 20% of plan allowance Substance Abuse Detoxification No charge 20% of plan allowance Inpatient rehabilitation services (limited to 30 days per calendar year) • Facility • Physician No charge No charge 20% of plan allowance 20% of plan allowance Outpatient rehabilitation services (limited to 30 days per calendar year) • Facility No charge 20% of plan allowance Prescription Drug $ 5 co-pay (retail generic) $10 co-pay (retail brand formulary) $20 (retail brand non-formulary) $10 co-pay (mail generic) $20 co-pay (mail brand formulary) $40 (mail brand non-formulary)
