Poudre School District Ssn# 21-690-002 Exhibit A
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POUDRE SCHOOL DISTRICT SSN# 21-690-002 EXHIBIT A Poudre School District Employee Health Clinic Service Provision Matrix Included Acute Provided Services Billed to Excluded Illness/Physical Exam Included Acute Injury Services Medical TPA Services Services Professional services in this category Items in this category are not covered include evaluation and treatment of Services in this category are common injuries under the capitated payment and will Specifically common illnesses typical to any typically treated in a primary care office or UC. be billed to the Employee's normal excluded services. primary care practice. Initial visit Visit codes using CPT codes. Initial visit plus PSD medical insurance. All charges This list is not plus any clinically appropriate short- any clinically appropriate short-term f/u will be applied by the medical TPA exhaustive or all- term f/u appointments are also appointments are also included. E.g. Suture according to the applicable plan inclusive. included. 30- day initial pharmacy removal after a laceration repair. benefits. prescription. Acute respiratory illness: URI's, All DME supplies such as crutches, influenza, bronchitis, otitis media, Joint sprains and muscle strains; commercial splints, air casts, wheel Obstetrical Care sinus infections, pharyngitis, strep Minor burn care chairs, walkers. throat, mononucleosis. Initial evaluation, stabilization and treatment Genitourinary problems: Urinary of fractures. (Complex fractures will be Radiology imaging: Technical tract infections, STD's, Vaginitis. referred to PCP or orthopedics at the component (obtaining image) is Hospital Skin disorders: Acne, insect bites, discretion of the provider.) Non-commercial included in capitated rate. Professional Rounding or bee stings, rashes, sunburn, DME supplies needed for fracture care component (interpretation of image) inpatient care of evaluation and initial treatment of including fiberglass and plaster splinting will be performed by a radiologist and any kind. common skin lesions. supplies and splint application, are included in billed separately. the capitation rate. All labs and pathology specimens Lacerations: Trunk down, single layer repair Gastrointestinal Disorders: unless otherwise listed in prior column for lacerations <2.5 cm in length and minor Vomiting and diarrhea, gastritis, titled in-office point of care labs will be sent After-hours call lacerations to the head and neck. Suture heartburn, abdominal pain. to PVH lab and billed separately. (e.g., coverage or removal included. (Complex laceration repairs blood testing, urine cultures, cytology, overnight or not included in the capitated fee and referral to Eye disorders: Conjunctivitis, mild Pap smears, pathology, throat cultures, weekend call. ER, PCP, or plastic surgeon the discretion of corneal abrasions etc.) the provider.) Specialty care; Neurologic/Psychiatric: Dizziness, Additional Covered Minor Surgical Procedures Pre-Operative All early childhood immunizations will headaches, migraines, concussions. such as: Nail Avulsion, Subungual hematoma evaluations; be provided through PCP office and Initial evaluation & management of evacuation, Cryotherapy for simple warts, I&D Long-term not stocked at EHC. routine behavioral diagnoses such as of abscess, Punch or shave skin biopsy chronic illness All immunizations outside of standard depression & anxiety. Initiation of (pathology charges billed to insurance), treatment; CDC schedule (e.g., travel and medical therapy solely at discretion Foreign body removal, Removal of simple Behavioral Health immigration immunizations). These of provider. Patients will be referred corneal foreign body, Control of epistaxis, services except for will also not be stocked. to EAS. simple Cerumen extraction, & ear irrigation acute management of new symptoms. All school age and adult participants may obtain physical exam services at the EHC and these services are covered under the capitation. PSD Misc. covered procedures: should encourage all participants to EKG including read unless sent to cardiology. Treatment of more complex or have these exams performed Emergency room Office spirometry and peak flow extensive lacerations/wound care than annually either by his/her care or ambulance Venipuncture for blood work drawn outlined in the prior section of established PCP or at the EHC. transfers. Tetanus vaccine when indicated for injury. included services. Scheduling restrictions may apply. Standard immunizations for school aged children and adults will be covered under the capitation. Newborn, infant Misc: Mild asthma exacerbations, In-Office Point of Care Labs: Worker's Compensation injuries or and preschool well short-term pharmaceutical refills. Rapid strep antigen testing( excludes culture) occupationally related illnesses: Staff child exams and Chronic Conditions: Short-term Urine analysis dip and micro.(does not include can provide initial evaluation and immunizations. issues related to chronic conditions. urine culture if indicated) treatment if so approved by PSD. All Participants (E.g. Diabetes w/ high glucose Stool hemoccult services rendered will be billed to PSD should be levels, high blood pressure. All Mononucleosis rapid antigen test Worker's Compensation carrier. All encouraged to chronic conditions should be Urine pregnancy testing complex injuries or injuries requiring have these exams primarily managed by PCP and/or Finger stick glucose recurring f/u will be referred to done through the subspecialists) Rapid influenza antigen testing. workers comp clinic. PCP office. .