Member Reimbursement. Upon implementation of the amended rule, the MCP shall follow OAC rule 5160-1-60.2 regarding direct reimbursement for out-of-pocket expenses incurred by members for Medicaid covered services during approved eligibility periods. If submitted properly by a member, the MCP shall accept the ODM approved direct reimbursement packet and begin the direct reimbursement process. If the MCP is the first contact a member makes regarding direct reimbursement, the MCP shall begin the direct reimbursement process but may use their own process and documents.
Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network Pharmacy, and they are unable to process the claim at the point of service you may pay for the prescription and may request Presbyterian Insurance Company, Inc., reimburse you. A Pharmacy Specialist will review and process your request for reimbursement based on the negotiated rate between Presbyterian Insurance Company, Inc., and the dispensing pharmacy minus any copay or coinsurance that may apply. Members will not be liable to a provider for any sums owed to the provider by Presbyterian. The Pharmacy Specialist needs the following information to determine reimbursement amounts. Please submit a Member Reimbursement Form and attach the itemized cash register receipt and the prescription drug detail (pharmacy pamphlet) along with the following information: • Patient’s name • Patient’s Date of Birth • Name of the drug • Quantity dispensed • NDC (National Drug Code) • Fill Date • Name of Prescriber • Name and phone number of the dispensing pharmacy • Reason for the purchase (nature of emergency) • Proof of Payment Member Reimbursement forms are available by calling our Presbyterian Customer Service Center at (000) 000-0000 or 0-000-000-0000, Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Please follow the mailing instructions on the Member Reimbursement Form. A Pharmacy Services Call Center is available 24 hours a day to providers, pharmacies and members to address pharmacy benefit questions. Please contact PCSC at 0-000-000-0000. A registered professional nurse or physician shall be immediately available by telephone 24 hours a day, seven days a week, to render utilization management determinations for providers. Presbyterian shall provide all members and providers with a toll-free telephone number by which to contact utilization management staff on at least a five day, 40 hours a week basis. All members must have immediate telephone access 24 hours a day, seven days a week, to their Primary Care Physician or the physician’s authorized on-call back-up provider. When these providers are unavailable, a registered nurse or physician on the utilization management staff must be available to respond to inquiries concerning emergency or urgent care. In the event Medically Necessary...
Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network Pharmacy, and they are unable to process the claim at point of service you can pay for the prescription and submit a Direct Member Reimbursement (DMR) form with an itemized receipt to us for reimbursement. The DMR form together with the itemized receipt must contain the following information: o Patient’s name and ID number o Name and quantity of the drug o Date purchased o Name and phone number of Practitioner/Provider o Name and phone number of pharmacy o Reason for the purchase (nature of emergency) o Proof of Payment Call P 505‐923‐5678 1‐800‐356‐2219 Direct Member Reimbursement (DMR) forms are available by calling our Presbyterian ‐ CSC Customer Service Center Monday through Friday from 7:00 a.m. to 6:00 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call our TTY number at 711 or toll-free at 0-000-000-0000 or visit the Pharmacy page of our website at xxx.xxx.xxx. Reconstructive Surgery Exclusion This benefit includes one or more exclusions as specified in the Exclusions section. Prior Auth Required Reconstructive Surgery from which an improvement in physiological function can reasonably be expected will be Covered if performed for the correction of functional disorders. Reconstructive Surgery must be prescribed by a Member’s Practitioner/Provider and requires Prior Authorization. For information regarding Reconstructive Surgery following a Mastectomy and Prophylactic Mastectomy, refer to the Women’s Health Care Section. Excl sion Rehabilitation and Therapy u Prior Auth Required This benefit includes one or more exclusions as specified in the Exclusions section. Rehabilitation and Therapy Services requires Prior Authorization. Cardiac Rehabilitation Services. Cardiac Rehabilitation benefits are available for continuous electrocardiogram (ECG) monitoring, progressive exercises and intermittent ECG monitoring. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. Pulmonary Rehabilitation Services. Pulmonary Rehabilitation benefits are available for Refer to progressive exercises and monitoring of pulmonary functions. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. Short-term Rehabilitation Services. Short-term Rehabilitatio...
Member Reimbursement. It is not anticipated that Members will make payment to any person or institution for Benefits provided under this Agreement, except as expressly stated herein. However, if a Member furnishes a claim form and written evidence satisfactory to Plan that he or she received Benefits covered under this Agreement, and that he or she made payment to the provider of such Benefits for same, Plan shall reimburse the Member for the Benefits rendered, upon verification of coverage by Plan that the Benefits were appropriately Authorized or constituted Emergency Services or Urgent Care Services.
Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network, however, if you go to an Out-of-network (outside of the 5- county area) Pharmacy, and they are unable to process the claim at point of service you may pay for the prescription and may request Presbyterian Health Plan to reimburse you. A Pharmacy Specialist will review and process your request for reimbursement based on the negotiated rate between Presbyterian Health Plan and the dispensing pharmacy minus any copay or coinsurance that may apply. Members will not be liable to a provider for any sums owed to the provider by Presbyterian. The Pharmacy Specialist needs the following information to determine reimbursement amounts. Please submit a Member Reimbursement Form and attach the itemized cash register and prescription drug detail (pharmacy pamphlet) along with the following information. • Patient’s Name • Patient’s Date of Birth • Name of the Drug • Quantity dispensed • NDC ( National Drug Code) • Fill Date • Name of Prescriber • Name and phone number of the dispensing pharmacy • Reason for the purchase (nature of emergency) • Proof of Payment Member Reimbursement forms are available by calling our Presbyterian Customer Service Center, Monday through Friday, from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call TTY 711. The Presbyterian Health Plan Pharmacy Service Team is available 24 hours a day to providers, pharmacies and members to address pharmacy benefit questions. Please contact them at (000) 000-0000 or 0-000-000-0000 (select option 6 when calling either number). A registered professional nurse or physician shall be immediately available by telephone seven days a week, 24 hours a day, to render utilization management determinations for providers. Presbyterian shall provide all members and providers with a toll-free telephone number by which to contact utilization management staff on at least a five-day, 40 hours a week basis. All members must have immediate telephone access seven days a week, 24 hours a day, to their PCP or the physician’s authorized on-call back-up provider. When these providers are unavailable, a registered nurse or physician on the utilization management staff must be available to respond to inquiries concerning emergency or urgent care. In the event Medically Necessary Covered servic...
Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network (outside of the 5-county area) Pharmacy, and they are unable to process the claim at point of service you can pay for the prescription and submit a Member Reimbursement Form. Reimbursement will be based on the negotiated rate between Presbyterian Health Plan and the dispensing pharmacy minus any copay or coinsurance that may apply. The form together with the itemized cash register receipt and the prescription drug detail (pharmacy pamphlet) must contain the following information: • Patient’s name • Patient’s Date of Birth • Name of the drug • Quantity dispensed • NDC (National Drug Code) • Fill Date • Name of Prescriber • Name and phone number of the dispensing pharmacy • Reason for the purchase (nature of emergency) • Proof of Payment Member Reimbursement forms are available by calling our Presbyterian Customer Service Center, Monday through Friday, from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call TTY 711. The Presbyterian Health Plan Pharmacy Service Team is available 24 hours a day to providers and pharmacies to address pharmacy benefit questions and Prior Authorization requests. Please contact the Provider Line at 0-000-000-0000. A registered professional nurse or physician shall be immediately available by telephone 24 hours a day, seven days a week, to render utilization management determinations for providers. Presbyterian shall provide all members and providers with a toll-free telephone number by which to contact utilization management staff on at least a five-day, 40 hours a week basis. All members must have immediate telephone access 24 hours a day, seven days a week, to their Primary Care Physician or the physician’s authorized on-call back-up provider. When these providers are unavailable, a registered nurse or physician on the utilization management staff must be available to respond to inquiries concerning emergency or urgent care. In the event Medically Necessary Covered services are not reasonably available through participating healthcare professionals, Presbyterian shall allow the PCP or other participating healthcare professional to refer a member to a non-participating healthcare professional and shall fully reimburse the non-participating healthcare...
Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network Pharmacy, and they are unable to process the claim at point of service you can pay for the prescription and submit a Direct Member Reimbursement (DMR) form with an itemized receipt to us for reimbursement. The DMR form together with the itemized receipt must contain the following information: o Patient’s name and ID number o Name and quantity of the drug o Date purchased o Name and phone number of Practitioner/Provider o Name and phone number of pharmacy o Reason for the purchase (nature of emergency) o Proof of Payment CSC Call P 505‐923‐5678 1‐800‐356‐2219 Direct Member Reimbursement (DMR) forms are available by calling our Presbyterian Customer Service Center Monday through Friday from 7:00 a.m. to 6:00 p.m. at (000) 000-0000 or 0-000-000-0000. Hearing impaired users may call our TTY number at 711 or toll-free at xxx.xxx.xxx.
Member Reimbursement. If a medical Emergency occurs outside of our Service Area and you use an In-network Pharmacy, you will be responsible for payment of the appropriate Copayment. We have a large, comprehensive pharmacy network; however, if you go to an Out-of-network Pharmacy, and they are unable to process the claim at point of service you can pay for the prescription and submit a Direct Member Reimbursement (DMR) form with an itemized receipt to us for reimbursement. Reimbursement will be based on the negotiated rate between Presbyterian Health Plan and the dispensing pharmacy minus any copay or coinsurance that may apply. The DMR form together with the itemized receipt must contain the following information: o Patient’s name and ID number o Name and quantity of the drug Exclusion Prior Auth Required Exclusion
Member Reimbursement. Each Member shall bear its own costs and expenses in entering into this Agreement and fulfilling its duties and obligations as a Member.
