Employer Health Programs (EHP) Outpatient Referral and Pre-Authorization Guidelines Important Information • This list is not all inclusive • To verify benefit coverage call 1-800-261-2393 • All procedures performed in Ambulatory Surgery Centers (Place of Service 24) require a referral to be submitted to the health plan. Fax clinical documentation for services that require Pre-Authorization to 410-424-4890 • All CPT Codes classified as unlisted by the American Medical Association require Pre-Authorization (i.e.49999, 69979) • AON Plan Members- Must stay in-network / No out-of-network benefits • Basic Plan Members- PCP Referral required/Must stay in-network / No out-of-network benefits • All Other EHP Plan Members-Have direct access to specialty providers in- or out-of-network (no referral required) • Laboratory/ Radiology- Participating freestanding facilities preferred • For additional information about EHP, refer to the website at: www.ehp.org
No Referral or • All EHP Plan Members (except for AON and Basic Plan) have direct access to specialty providers in- and out-of-network (no referral Pre-Authorization required, except if listed in the Pre-Authorization Section) Required Nutritional Counseling – Initial 2 Visits Wound Clinic - Initial 10 Visits Referral • Fax request to Outpatient Intake Services to 410-424-4890 (For plan specific benefits refer to grid below) Required • All AON and Basic Plan members - Referral required for all services • The health plan will perform Medical Review of requested services before they are rendered • Fax pertinent clinical documentation for Medical Review to 410-762-5205 • For plan specific benefits refer to grid below Pre-Authorization • Fax documentation for all Durable Medical Equipment (DME) to Medical Review at 410-762-5250 Required (For plan specific benefits refer to grid below) • For urgent requests (delay will seriously jeopardize the life or health of a member, or severe pain), mark Urgent and fax to 410-762-5205 or call 1-800-261-2421 • To check authorization status, access McNet (www.jhhcmcnet.com) or call 1-800-654-9728 Acne Surgery ENT – Uvulectomy, palatopharyngoplasty, Plastic Surgery (All) Ambulance, non emergent LAUP (Laser Assisted Uvuloplasty) Podiatry-Bunionectomy Botox Type A and B Feeding Programs Prosthetics Breast Reduction Gastroenterology (GI)-Capsule Endoscopy Pulmonology-Pulmonary Rehabilitation Cardiology-Cardiac Exercise Program for patients with PVD Gynecomastia Surgery Radiology-CT Angiogram Cardiology-Cardiac Rehabilitation Home Health Care Radiology-Dexa Scans Cardiology-External Counterpulsation Hospice Radiology-Electron Beam Computer Carpal Tunnel Surgical Decompression Hyperbaric Oxygen Therapy Tomograph Clinical Trials (including NCI trials) Laboratory-Genetic Testing Radiology-MEG/MSI Dermatology-Phototherapy and Photochemotherapy (PUVA) Neuropsychological Testing Radiology-PET Scan Dermatology-Pulse Dye Laser for Port Wine Stain Neurostimulators Radiology-MRI of Breast Dermatology-Skin Tags Nutrition Counseling - > 2 visits Speech Therapy (non developmental) DME Occupational Therapy (see grid below) Transplants (All) Endocrinology-Continuous Glucose Monitoring Ophthalmology-Blepharoplasty Vascular-Sclerotherapy ENT- Bone Anchored Hearing Devices Ophthalmology-Chalazion Excision Vascular-Varicose Vein Ligation ENT-Cochlear Implants Oral Surgery-TMJ Treatment Wig ENT-Rhinoplasty Oral Surgery-Alveolectomy/Alveoplasty Wound Clinic - > 10 visits ENT-Septoplasty Orthotics Wound Vac ENT-Sleep Study (home only) Physical Therapy (see grid below)
Johns Hopkins Health Johns Hopkins Health Plan Specific AON Broadway Services, Inc. Chester River Johns Hopkins System Corp/Hospital/ System Corp/Hospital/ Johns Hopkins Johns Hopkins Health System Bayview Medical Center Howard County General Hospital Howard County General Hospital University University Student E00013 Basic Plan Premium Plan Benefits E00008 E00019 E00006 Classic Plan Health Program E00007 E00020, E00040, E00041, E00025, E00045, E00046, Contact EHP Customer Service E00009 E00042, E00043, E00050, E00060, E00047, E00048, E00055, E00065, E00015 E00016 for plan specific limitations E00161 E00140, E00142 E00145, E00147 E00151 Abortion - Elective Pre-Authorization No - Except for Incest, Pre-Authorization Pre-Authorization Pre-Authorization Pre-Authorization Pre-Authorization Pre-Authorization Required Rape, Life of Mother Required Required Required Required Required Required Pre-Authorization Anesthesia No Benefit Anesthesia Anesthesia Anesthesia Anesthesia Pre-AuthorizationPre-Authorization Acupuncture Required Pain Control Pain Control Pain Control Pain Control Pain Control Required Therapeutic Purposes Therapeutic Purposes
Biofeedback No Benefit No Benefit No Benefit No Benefit Yes, for Voiding Dysfunction Yes, for Voiding Dysfunction Pre-Authorization No Benefit Pre Authorization Required Pre Authorization Required Required Contraceptive Devices, IUD No Benefit No Benefit Covered Yes, Limited to IUD Pre-Authorization Covered Yes CoveredYes Covered and Diaphragms and Diaphragms Required
Pre-Authorization No Benefit Pre-Authorization Pre-Authorization Pre-Authorization Diabetes Education Classes No Benefit No Benefit Required Required Required Required No Benefit Gastric Bypass/ Bariatric No Benefit Pre-Authorization No Benefit Pre-Authorization Pre-Authorization Pre-Authorization Surgery No Benefit requiredNo Benefit Required required requiredRequired required Requiredrequired Required Up to Age 18 Up to Age 18 Up to Age 18 Up to Age 18 Hearing Aids No Benefit No Benefit No Benefit Pre-Authorization Pre-Authorization Pre-Authorization Pre-Authorization No Benefit Required Required Required Required Infertility No Benefit No Benefit No Benefit Pre-Authorization No Benefit Pre-Authorization Pre-Authorization Pre-Authorization Required Required Required Required
Physical No Referral or No Referral or No Referral or No Referral or No Referral or Pre Authorization No Referral or Pre Authorization No Referral or No Referral or Therapy/Occupational Pre Authorization Pre Authorization Pre Authorization Pre Authorization Required Visits 1-12 Required Visits 1-12 Pre Authorization Pre Authorization Therapy Required Required Required required Required Pre Authorizationrequired Required Pre Authorization Requiredrequired Requiredrequired Required Visits > 12 Visits > 12
Commonly Requested • For plan specific benefits refer to grid above Non-Covered Services
Autopsy Hot Water Bottle Private Duty Nursing Bed Boards Ice Bags Pulse Electrical Stimulation for OA of the Knee Breast Ductal Lavage and Fiberoptic Ductoscopy Interferential Therapy Radiofrequency Ablation for Chronic Back Pain Cosmetic Surgery Intradiscal Electrothermal Therapy (IDET) Sex Change Cryopreservation of Pre-embryos Investigational Health Services/Equipment Speech Therapy (developmental) Diapers (including pull-ups and Depends) (not FDA approved) Sterilization Reversal Exercise Equipment and Devices LASIK Eye Surgery Structural Modi cation to the Home Eye Exercises (AKA visual training/orthoptics) Learning Disabilities (refer to school system) Surrogacy Fecal DNA Massage Therapy Tray Tables Grab Bars Naturopathic Treatment Vitamin and Mineral Supplements (Oral) Hypnosis Nutritional Supplements (Oral) Weight Loss Programs (ie Weight Watchers) Heating Pads or Lamps Podiatry - Routine Foot Care - Except PVD and DM Wheelchair Tray Table Home Health Aides Diagnosis Only Whirlpools/Whirlpool Bath Equipment • Providers call 410-424-4845 or 1-800-261-2429 • AON and Basic Plan Members - Must coordinate care with EHP Behavioral Health. All other plan members do not need to coordinate Behavioral Health care with EHP Behavioral Health. • The health plan will perform review of below requested services before they are rendered Pre-Authorization Required Electro Convulsive Therapy Light Box Therapy-SAD Psychological Testing
Resources • The following resources may be helpful in meeting the needs of the EHP member and verifying benefit limitations
EHP Care Management-call 1-800-261-2421 or 410-424-4480 Behavioral Health ServicesRequired visits Members 13-60 – call 1-888-281-3186 or 410-424-4476 EHP Customer Service-call 1-800-261-2393 Caremark Website - www.caremark.com EHP Website-www.ehp.org Caremark Customer Service- call -1-800-213-0879 Effective UM January 2010