Scans in an Outpatient Setting Sample Clauses

Scans in an Outpatient Setting. Positron Emission Tomography (PET) is a noninvasive diagnostic imaging procedure that quantifies biochemical processes in living tissue. Positron Emission Tomography (PET) scans in an outpatient setting require Prior Authorization. Practitioner/Provider Services This benefit has one or more exclusions as specified in the Exclusions Section. Practitioner/Provider services are those services that are reasonably required to maintain good health. Practitioner/Provider services include, but are not limited to, periodic examinations and office visits by: • A licensed Practitioner/Provider • Specialist services provided by other Health Care Professionals who are licensed to practice, are certified, and practicing as authorized by applicable law or authority • A medical group • An independent practice association • Other authority authorized by applicable state law Some Practitioner/Provider services require Prior Authorization. Refer to the Prior Authorization Section for Prior Authorization requirements. This Benefit includes, but not limited to, consultation and Health Care Services and supplies provided by your Practitioner/Provider as shown below: • Office visits/telemedicine visits provided by a qualified Practitioner/Provider. • Video Visits provided online between a designated Practitioner/Provider and patient about non-urgent healthcare matters. • Outpatient surgery and Inpatient surgery including necessary anesthesia services. Anesthesia may include hypnotherapy. • Hospital and Skilled Nursing Facility visits as part of continued supervision of Covered care‌‌ • Allergy Services, including testing and serum • Sterilization procedures • Student Health Centers: Dependent Students attending school either in New Mexico or outside New Mexico may receive care through their Primary Care Physician or at the Student Health Center. A Prior Authorization is not needed prior to receiving care from the Student Health Center. Services provided outside of the Student Health Center are limited to Medically Necessary Covered services for the initial care or treatment of an Emergency Health Care Service or Urgent Care situation. • Second medical opinions. Cost Sharing will apply when you or your Practitioner/Provider requests the second medical opinion. Cost Sharing will not apply if we require a second medical opinion to evaluate the medical appropriateness of a diagnosis or service. Prescription Drugs/Medications This benefit has one or more exclusions as specified in th...
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Scans in an Outpatient Setting. Positron Emission Tomography (PET) is a noninvasive diagnostic imaging procedure that quantifies biochemical processes in living tissue. Positron Emission Tomography (PET) scans in an outpatient setting require Prior Authorization. Practitioner/Provider Services Services provided by an Excluded Provider are not Covered. Any benefit or service, including pharmaceuticals, provided by an Excluded Provider as defined and maintained by the following regulatory agencies: Department of Health and Human Services; Office of the Inspector General (OIG); U.S. Department of Health; the General Services Administration; and the Office of Personnel Management, Office of Inspector General, which includes, but is not limited to, the: • Excluded Parties Lists System (EPLS), • List of Excluded Individuals/Entities (LEIE), • Office of Personnel Management (OPM). Office Visits, listed below, are not Covered. • Get acquainted visits without physical assessment or diagnostic or therapeutic intervention provided are not Covered. Infertility services, listed below, are not Covered. • Prescription Drugs and Injections • Reversal of voluntary sterilization is not Covered. • Donor sperm is not Covered. • In-vitro, Gamete Intra Fallopian Transfer (GIFT) and zygote intrafallopian transfer (ZIFT) fertilization are not Covered. • Storage or banking of sperm, ova (human eggs), embryos, zygotes or other human tissue is not Covered. Prescription Drugs/Medications • Prescription Drugs/Medications that require a Prior Authorization when Prior Authorization was not obtained are not Covered. • New Prescription Drugs/Medications for which the determination of criteria for Coverage has not yet been established by our Pharmacy and Therapeutics Committee are not Covered. • Prescription Drugs/Medications purchased outside the United States are not Covered. • Prescription Drugs/Medications, medicines, treatments, procedures, or devices that we determine are Experimental or Investigational are not Covered. • Prescription Drugs/Medications that have not been approved by the FDA are not Covered. • Prescription Drugs/Medications that are identified by Drug Efficacy Study Implementation (DESI) as Less than Effective (LTE) DESI drugs are not Covered. • Replacement Prescription Drugs/Medications resulting from loss, theft, or destruction are not Covered. • Disposable medical supplies, except when provided in a Hospital or a Practitioner’s/Provider’s office or by a home health professional, are not Covered. ...
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Related to Scans in an Outpatient Setting

  • Outpatient Services The following services are covered only at the Primary Care Provider’s office[selected by a [Member], or elsewhere [upon prior written Referral by a [Member]'s Primary Care Provider ]:

  • Inpatient Services Hospital This plan covers services provided while inpatient in a general or specialty hospital including, but not limited to the following: • anesthesia; • diagnostic tests and lab services; • dialysis; • drugs; • intensive care/coronary care; • nursing care; • physical, occupational, speech and respiratory therapies; • physician’s services while hospitalized; • radiation therapy; • surgery related services; and • room and board. Notify us if you are admitted from the emergency room to a hospital that is not in our network. Our Customer Service Department can assist you with any questions you may have about your coverage. Rehabilitation Facility This plan covers rehabilitation services received in a general hospital or specialty hospital. Coverage is limited to the number of days shown in the Summary of Medical Benefits.

  • Outpatient Dental Anesthesia Services This plan covers anesthesia services received in connection with a dental service when provided in a hospital or freestanding ambulatory surgical center and: • the use of this is medically necessary; and • the setting in which the service is received is determined to be appropriate. This plan also covers facility fees associated with these services.

  • Outpatient emergency and urgicenter services within the service area The emergency room copay applies to all outpatient emergency visits that do not result in hospital admission within twenty-four (24) hours. The urgicenter copay is the same as the primary care clinic office visit copay.

  • Financial Management Services ‌ Definition: Financial Management Services includes the planning, directing, monitoring, organizing, and controlling of the monetary resources of an organization. Examples: Service areas that are included under the Financial Management Services discipline include, but are not limited to the following:

  • Medically Necessary Services for the State plan services in Addendum VIII. B medically necessary has the meaning in Wis. Admin. Code DHS §101.03(96m): services (as defined under Wis. Stat. § 49.46

  • Availability of Verizon Telecommunications Services 3.1 Verizon will provide a Verizon Telecommunications Service to PCS for resale pursuant to this Attachment where and to the same extent, but only where and to the same extent, that such Verizon Telecommunications Service is provided to Verizon’s Customers.

  • Financial Management System Subrecipient shall establish and maintain a sound financial management system, based upon generally accepted accounting principles. Contractor’s system shall provide fiscal control and accounting procedures that will include the following:

  • Project Management Services Contractor shall provide business analysis and project management services necessary to ensure technical projects successfully meet the objectives for which they were undertaken. Following are characteristics of this Service:

  • AIN Selective Carrier Routing for Operator Services, Directory Assistance and Repair Centers 4.3.1 BellSouth will provide AIN Selective Carrier Routing at the request of <<customer_name>>. AIN Selective Carrier Routing will provide <<customer_name>> with the capability of routing operator calls, 0+ and 0- and 0+ NPA (LNPA) 555-1212 directory assistance, 1+411 directory assistance and 611 repair center calls to pre-selected destinations.

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