UTILIZATION MANAGEMENT GUIDELINE – 9.03.507 Photography

Effective Date: Feb. 1, 2021 RELATED MEDICAL POLICIES/GUIDELINES: Last Revised: Jan. 21, 2021 None Replaces: N/A

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COVERAGE GUIDELINE | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE REVIEW | REFERENCES | HISTORY

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Introduction

The fundus of the is the back of the inner eye. Fundus photography uses a microscope with an attached camera to take a digital photograph of this area. The photo captures images of structures such as the (that converts light into signals the brain can understand), the (that sends the signals to the brain), and the macula (allows a person to have sharp, clear vision straight ahead). Fundus photography is most useful when a disease is suspected or a condition needs to be monitored. It’s also useful to see if the retina has been damaged after eye trauma or injury. Fundus photography is unnecessary when a routine eye exam does not indicate any eye problems or symptoms. This policy describes when fundus photography may be considered medically necessary.

Note: The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a service may be covered.

Coverage Guideline

Medical Necessity Fundus Photography may be considered medically necessary to evaluate abnormalities in the fundus of the eye, follow the progression of a known disease or evaluate the response to treatment of an eye injury.

Indications that may need examination or monitoring include, but are not limited to the following: • Abnormal electro-oculogram (EOG) or oculomotor studies • Abnormal retinal function studies • Abnormal visually evoked potential • Age-related • Anti-malarial therapy (eg, Plaquenil, hydroxychloroquine, Aralen, or chloroquine) when fundus changes are noted during standard o For example, automated threshold visual field testing, optical coherence tomography, fundus auto fluorescence imaging, multifocal electro-retinogram (Note: Drug may also be taken for treatment of rheumatoid arthritis or lupus) • Autoimmune disease involving the eye o For example, systemic lupus erythematosus, rheumatoid arthritis and other inflammatory polyarthropathies • Carcinoma in situ of the eye • Choroid disorders o For example, chorioretinal inflammation • Color vision deficiencies • Congenital • Suspected congenital anomalies of the posterior segment of the eye • Other congenital corneal malformations (Peters anomaly) • • Disorders of aromatic amino-acid metabolism affecting the fundus • Disorders of • Disorders of optic nerve and visual pathways o For example, • Glaucoma • Glaucoma suspected/pre-glaucoma when consistently elevated intraocular pressure is documented • Infection of the eye o For example, endophthalmitis, histoplasmosis, human immunodeficiency virus (HIV), syphilis, cytomegalovirus, congenital rubella, toxoplasmosis • Neoplasm of the choroid, cranial nerves, eyeball or retina

Page | 2 of 9 ∞ Medical Necessity • Ocular trauma or foreign body in the eye • Pseudotumor cerebri (high pressure within the skull for no apparent reason) • and retinal defects • Retinopathy of prematurity (ROP) for infants less than 1500 grams or born at 30 weeks gestation or less • Sickle-cell anemia • Tuberous sclerosis • Visual field exam abnormality when the study results will change the treatment plan

Fundus photography is considered not medically necessary when the routine (eye) exam shows normal clinical findings.

Fundus photography is considered not medically necessary when no symptoms are present.

Fundus photography is considered not medically necessary to routinely screen for eye (ocular) disorders. Remote imaging used to detect retinal disease is considered screening.

Documentation Requirements The medical records submitted for review should document that medical necessity criteria are met, including detailed history and physical supporting abnormalities or a known condition that needs to be monitored, or to follow up on the response to treatment of an eye injury. Any changes in management because of the findings should also be documented.

Coding

Code Descriptor CPT 92250 Fundus photography with interpretation and report

ICD-10 Diagnosis Codes - Covered A50.01 Early congenital syphilitic oculopathy

A50.30 Late congenital syphilitic oculopathy, unspecified

A50.44 Late congenital syphilitic optic nerve atrophy

Page | 3 of 9 ∞ Code Descriptor A51.43 Secondary syphilitic oculopathy

A52.15 Late syphilitic neuropathy

A52.71 Late syphilitic oculopathy

B20 Human immunodeficiency virus [HIV] disease

B25.0 – B25.9 Cytomegaloviral disease

B39.4 – B39.9 Histoplasmosis

B50.0 – B52.9 Malaria

B58.00 – B58.09 Toxoplasma oculopathy

C69.00 – C69.92 Malignant neoplasm of eye and adnexa

C79.49 Secondary malignant neoplasm of other parts of nervous system

D09.20 – D09.22 Carcinoma in situ of eye

D31.00 – D31.92 Benign neoplasm of eye and adnexa

D33.3 Benign neoplasm of cranial nerves

D49.81 Neoplasm of unspecified behavior of retina and choroid

D57.00 – D57.819 Sickle-cell disorders

E08.00 – E11.9 mellitus

E70.20 – E70.9 Disorders of aromatic amino-acid metabolism

G35 Multiple sclerosis

G93.2 Benign intracranial hypertension (pseudotumor cerebri)

H27.10 – H27.119 Subluxation of lens

H27.131 - H27.139 Posterior dislocation of lens

H30.001 – H30.93 Chorioretinal inflammation

H31.00 – H31.9 Other diseases of choroid

H32 Chorioretinal disorders in diseases classified elsewhere

H33.001 – H33.8 Retinal detachment and breaks

H34.00 – H34.9 Retinal vascular occlusions

Page | 4 of 9 ∞ Code Descriptor H35.00 – H35.9 Other retinal disorders

H36 Retinal disorders in diseases classified elsewhere

H40.001 – H40.9 Glaucoma

H42 Glaucoma in diseases classified elsewhere

H43.00 – H43.9 Disorders of vitreous body

H44.001 – H44.9 Disorders of globe

H46.00 – H47.9 Disorders of optic nerve and visual pathways

H53.50 – H53.59 Color vision deficiencies

H59.031 – H59.039 Cystoid macular edema following surgery

L93.0 – L93.2 Lupus erythematosus

M05.00 – M14.89 Rheumatoid arthritis and inflammatory polyarthropathies

M32.0 – M32.9 Systemic lupus erythematosus (SLE)

M35.00 Sicca syndrome, unspecified

M35.01 Sicca syndrome with keratoconjunctivitis

P35.0 – P35.9 Congenital viral diseases (congenital rubella syndrome)

P37.0 – P37.9 Other congenital infectious and parasitic diseases

Q13.4 Other congenital corneal malformations (Peters anomaly)

Q14.0 – Q14.9 Congenital malformations of posterior segment of eye

Q15.0 Congenital glaucoma

Q85.1 Tuberous sclerosis

Q85.8 – Q85.9 Other and unspecified phakomatoses, not elsewhere classified

Q87.0 Congenital malformation syndromes predominantly affecting facial appearance

Q87.42 Marfan's syndrome with ocular manifestations

Q87.89 Other specified congenital malformation syndromes, not elsewhere classified

Q89.8 Other specified congenital malformations

Q99.2 Fragile X chromosome

Page | 5 of 9 ∞ Code Descriptor R94.110 – R94.118 Abnormal results of function studies of eye

S05.00XA – S05.92XS Injury of eye and orbit

Note: CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). HCPCS codes, descriptions and materials are copyrighted by Centers for Medicare Services (CMS).

Related Information

In order to be a covered service, the results from fundus photography must have a direct impact on the decision-making related to the patient’s medical care and treatment. In general, fundus photographs are not needed to confirm the presence of a condition but are necessary in determining the progression of a known disease that affects the eye.

The term “retinal fundus” means the inside or back of the eyeball that is seen through the pupil during a dilated . Fundus photography uses a special camera to photograph structures behind the lens of the eye including the choroid, optic nerve, retina and vitreous. The image can be either digital or a hard copy photograph.

Fundus photography is used to evaluate and document vascular and structural changes related to eye conditions not part of a routine screening eye examination. Some of these conditions include choroid disturbances, diabetic retinopathy, glaucoma, macular degeneration, multiple sclerosis or other central nervous system abnormalities, and tumors of the retina.

A comprehensive eye examination includes evaluation of any signs and symptoms present at the time of the office visit. Signs and symptoms involving the eye can be divided into three basic categories: abnormalities of vision, abnormalities of eye appearance, and abnormalities of eye feelings/sensation such as pain and discomfort.

Patients without any signs or symptoms should not have routine imaging studies of their eyes if the only goal is to document normal eye anatomy (see Practice Guidelines and Position Statements directly below).

Evidence Review

Page | 6 of 9 ∞ Practice Guidelines and Position Statements

American Academy of Ophthalmology (AAO)

The AAO recommends against imaging tests for patients without symptoms or signs of significant eye disease. In their statement for ChoosingWisely they say the following:

If patients do not have symptoms or signs of significant disease pathology, then clinical imaging tests are not generally needed because a comprehensive history and physical examination will usually reveal if eye disease is present or is getting worse. Examples of routine imaging include visual-field testing; optical coherence tomography (OCT) testing; retinal imaging of patients with diabetes; and neuroimaging or fundus photography. If symptoms or signs of disease are present, then imaging tests may be needed to evaluate further and to help in treatment planning.

Available at URL: http://www.choosingwisely.org/clinician-lists/american-academy- ophthalmology-routine-imaging-for-patients-without-symptoms-or-signs-of-eye- disease/ Accessed January 6, 2021

All AAO Preferred Practice Pattern (PPP) guidelines are available at: http://www.aaojournal.org/content/preferred-practice-pattern Accessed March 2020

Institute for Clinical Systems Improvement (ICSI)

The ICSI guideline (Sixteenth Edition/July 2014) for Diagnosis and management of type 2 diabetes mellitus (T2DM) in adults recommends the following:

A dilated eye examination for diabetic eye disease performed by an ophthalmologist or optometrist is recommended annually for patients with T2DM. Less frequent exams (every two to three years) may be considered in the setting of a normal eye exam. The role of fundus photography is still being considered but does not replace a comprehensive exam.

Available at URL: https://www.icsi.org/wp-content/uploads/2019/02/Diabetes.pdf Accessed January 6, 2021

References

Page | 7 of 9 ∞ 1. American Academy of Ophthalmology (AAO). Age-related macular degeneration. Preferred Practice Pattern. San Francisco, CA: AAO; 2019. https://www.aaojournal.org/article/S0161-6420(19)32091-3/pdf Accessed January 6, 2021

2. American Academy of Ophthalmology (AAO). Primary open-angle glaucoma. Preferred Practice Pattern. San Francisco, CA: AAO; 2015. https://www.aaojournal.org/article/S0161-6420(15)01276-2/pdf Accessed January 6, 2021

3. American Academy of Ophthalmology (AAO). Primary open-angle glaucoma suspect. Preferred Practice Pattern. San Francisco, CA: AAO; 2015. https://www.aaojournal.org/article/S0161-6420(15)01278-6/pdf Accessed January 6, 2021

4. American Academy of Ophthalmology (AAO). Primary angle closure. Preferred Practice Pattern. San Francisco, CA: AAO; 2015. https://www.aaojournal.org/article/S0161-6420(15)01271-3/pdf Accessed January 6, 2021

5. American Academy of Ophthalmology (AAO). Diabetic retinopathy. Preferred Practice Pattern. San Francisco, CA: AAO; 2019 https://www.aaojournal.org/article/S0161-6420(19)32092-5/pdf Accessed January 6, 2021

6. Soloman, S, Chew E, Duh E, et al. Diabetic Retinopathy: A Position Statement by the American Diabetes Association. Diabetes Care 2017; 40 (3): 412-418. PMID: 28223445.

7. Marmor MF, Kellner U, Lai TY, et al. Revised recommendations on screening for chloroquine and hydroxychloroquine retinopathy. Ophthalmology. 2011; 118(2):415-422.

8. Marmoor MF, Kellner U, Lai TY, et al. Recommendations on screening for chloroquine and hydroxychloroquine retinopathy (2016 Revision). Ophthalmology. 2016; Jun; 123 (6): 1386-94. PMID 26992838

9. Centers for Medicare & Medicare Services (CMS). Local Coverage Determination (LCD): Fundus photography (L33670). First Coast Service Options, Inc - MAC Part B. Medicare Coverage Database. Baltimore, MD: CMS; effective October 1, 2015. Revised October 1,2019. https://www.cms.gov/medicare-coverage-database/details/lcd- details.aspx?LCDId=33670&ver=24&Cntrctr=All&UpdatePeriod=770&bc=AQAACAAAgAAA&. Accessed January 6, 2021

History

Date Comments 04/01/16 New UM Guideline, approved March 8, 2016. Add to Vision section. Fundus photography may be considered medically necessary for the indications listed in the guideline. Routine fundus photography or for asymptomatic patients is not medically necessary because it is not clinically indicated based on the specialty practice guidelines. This policy will be effective August 1, 2016, following 90-day provider notification.

07/01/16 Interim Review, approved June 14, 2016. Policy updated to indicate screening for eye (ocular) disorders as not medically necessary; previously listed as investigational. CPT codes removed with the exception of 92250.

02/01/17 Interim Review, approved January 10, 2017. Added clarification that glaucoma- suspected/pre-glaucoma is evidenced by abnormal results from the usual screening test for glaucoma. Indications simplified and put in alphabetical order. Practice Guideline added from the ICSI added.

07/01/17 Annual Review, approved June 6, 2017. Policy updated with literature review. Clarifying edits made to policy section. Investigational policy statement removed; The intent of

Page | 8 of 9 ∞ Date Comments this policy is medically necessary when criteria are met, not medically necessary when criteria are not met. Clarified Plaquenil as anti-malarial drug.

08/15/17 Updated Coding table to include covered diagnosis codes and code ranges.

05/18/18 Coding update, removed diagnosis code Z79.899.

06/01/18 Annual Review, approved May 3, 2018. Medical necessity statements edited for clarity. Intent did not change. Reference 1 added. Otherwise policy statements unchanged. Added diagnosis codes M35.00, M35.01, and Q15.0 to policy.

04/01/19 Annual Review, approved March 19, 2019. Reference 2 added. Minor edits of covered diagnoses for clarity; otherwise policy statement unchanged.

04/01/20 Annual Review, approved March 3, 2020. UM Guideline reviewed. References added. Guideline statements unchanged.

02/01/21 Annual Review, approved January 21, 2021. UM Guideline reviewed. Guideline statements unchanged.

Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). ©2021 Premera All Rights Reserved.

Scope: Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply. This medical policy does not apply to Medicare Advantage.

Page | 9 of 9 ∞

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ይገባዎት ይሆናል። ይህን መረጃ እንዲያገኙ እና ያለምንም ክፍያ በቋንቋዎ እርዳታ እንዲያገኙ መብት maipanggep iti apliksayonyo wenno coverage babaen iti Premera Blue አለዎት።በስልክ ቁጥር 800-722-1471 (TTY: 800-842-5357) ይደውሉ። Cross. Daytoy ket mabalin dagiti importante a petsa iti daytoy a pakdaar. Mabalin nga adda rumbeng nga aramidenyo nga addang sakbay dagiti Arabic): partikular a naituding nga aldaw tapno mapagtalinaedyo ti coverage ti) العربية salun-atyo wenno tulong kadagiti gastos. Adda karbenganyo a mangala iti يحوي ھذا اإلشعار معلومات ھامة . قد يحوي ھذا اإلشعار معلومات مھمة بخصوص طلبك أو daytoy nga impormasion ken tulong iti bukodyo a pagsasao nga awan ti التغطية التي تريد الحصول عليھا من خالل Premera Blue Cross. قد تكون ھناك تواريخ مھمة .(bayadanyo. Tumawag iti numero nga 800-722-1471 (TTY: 800-842-5357 في ھذا اإلشعار . وقد تحتاج التخاذ إجراء في تواريخ معينة للحفاظ على تغطيتك الصحية أو للمساعدة في دفع التكاليف . يحق لك الحصول على ھذه المعلومات والمساعدة بلغتك دون تكبد أية تكلفة . اتصل :(Italiano (Italian بـ(TTY: 800-842-5357) 800-722-1471 Questo avviso contiene informazioni importanti. Questo avviso può contenere 中文 (Chinese): informazioni importanti sulla tua domanda o copertura attraverso Premera 本通知有重要的訊息。 本通知可能有關於您透過 Premera Blue Cross 提交的 Blue Cross. Potrebbero esserci date chiave in questo avviso. Potrebbe 申請或保險的重要訊息。本通知內可能有重要日期。您可能需要在截止日期 essere necessario un tuo intervento entro una scadenza determinata per 之前採取行動，以保留您的健康保險或者費用補貼。您有權利免費以您的母 consentirti di mantenere la tua copertura o sovvenzione. Hai il diritto di ottenere queste informazioni e assistenza nella tua lingua gratuitamente. 語得到本訊息和幫助。請撥電話 。 800-722-1471 (TTY: 800-842-5357) Chiama 800-722-1471 (TTY: 800-842-5357).

037338 (07-2016) 日本語 (Japanese): Română (Romanian): この通知には重要な情報が含まれています。この通知には、 Premera Blue Prezenta notificare conține informații importante. Această notificare Cross の申請または補償範囲に関する重要な情報が含まれている場合があ poate conține informații importante privind cererea sau acoperirea asigurării ります。この通知に記載されている可能性がある重要な日付をご確認くだ dumneavoastre de sănătate prin Premera Blue Cross. Pot exista date cheie în aceast notificare. Este posibil s fie nevoie s ac iona i pân la anumite さい。健康保険や有料サポートを維持するには、特定の期日までに行動を ă ă ă ț ț ă termene limită pentru a vă menține acoperirea asigurării de sănătate sau 取らなければならない場合があります。ご希望の言語による情報とサポー asistența privitoare la costuri. Aveți dreptul de a obține gratuit aceste トが無料で提供されます。800-722-1471 (TTY: 800-842-5357)までお電話 informații și ajutor în limba dumneavoastră. Sunați la 800-722-1471 ください。 (TTY: 800-842-5357).

한국어 (Korean): Pусский (Russian): 본 통지서에는 중요한 정보가 들어 있습니다 . 즉 이 통지서는 귀하의 신청에 Настоящее уведомление содержит важную информацию. Это 관하여 그리고 Premera Blue Cross 를 통한 커버리지에 관한 정보를 уведомление может содержать важную информацию о вашем Premera Blue Cross. 포함하고 있을 수 있습니다 . 본 통지서에는 핵심이 되는 날짜들이 있을 수 заявлении или страховом покрытии через В настоящем уведомлении могут быть указаны ключевые даты. Вам, 있습니다. 귀하는 귀하의 건강 커버리지를 계속 유지하거나 비용을 절감하기 возможно, потребуется принять меры к определенным предельным 위해서 일정한 마감일까지 조치를 취해야 할 필요가 있을 수 있습니다 . срокам для сохранения страхового покрытия или помощи с расходами. 귀하는 이러한 정보와 도움을 귀하의 언어로 비용 부담없이 얻을 수 있는 Вы имеете право на бесплатное получение этой информации и 권리가 있습니다 . 800-722-1471 (TTY: 800-842-5357) 로 전화하십시오 . помощь на вашем языке. Звоните по телефону 800-722-1471 (TTY: 800-842-5357). ລາວ (Lao): Fa’asamoa (Samoan): ້ ້ ້ ້ ແຈ້ງການນີ ມີ ຂໍ ມູ ນສໍ າຄັ ນ. ແຈ້ງການນີ ອາດຈະມີ ຂໍ ມູ ນສໍ າຄັ ນກ່ ຽວກັບຄໍ າຮ້ອງສະ Atonu ua iai i lenei fa’asilasilaga ni fa’amatalaga e sili ona taua e tatau ໝັ ກ ຫືຼ ຄວາມຄຸ້ ມຄອງປະກັນໄພຂອງທ່ານຜ່ານ Premera Blue Cross. ອາດຈະມີ ona e malamalama i ai. O lenei fa’asilasilaga o se fesoasoani e fa’amatala ວັນທີ ສໍ າຄັ ນໃນແຈ້ງການນີ້ . ທ່ານອາດຈະຈໍ າເປັ ນຕ້ອງດໍ າເນີ ນການຕາມກໍ ານົ ດ atili i ai i le tulaga o le polokalame, Premera Blue Cross, ua e tau fia maua ເວລາສະເພາະເພື່ ອຮັກສາຄວາມຄຸ້ ມຄອງປະກັນສຸ ຂະພາບ ຫືຼ ຄວາມຊ່ວຍເຫືຼ ອເລື່ ອງ atu i ai. Fa’amolemole, ia e iloilo fa’alelei i aso fa’apitoa olo’o iai i lenei fa’asilasilaga taua. Masalo o le’a iai ni feau e tatau ona e faia ao le’i aulia le ້ ້ ຄ່ າໃຊ້ຈ່າຍຂອງທ່ານໄວ້ . ທ່ານມີ ສິ ດໄດ້ ຮັບຂໍ ມູ ນນີ ແລະ ຄວາມຊ່ວຍເຫືຼ ອເປັ ນພາສາ aso ua ta’ua i lenei fa’asilasilaga ina ia e iai pea ma maua fesoasoani mai ai ຂອງທ່ານໂດຍບໍ່ ເສຍຄ່ າ. ໃຫ້ໂທຫາ 800-722-1471 (TTY: 800-842-5357). i le polokalame a le Malo olo’o e iai i ai. Olo’o iai iate oe le aia tatau e maua atu i lenei fa’asilasilaga ma lenei fa’matalaga i legagana e te malamalama i 徶羶ែខមរ (Khmer): ai aunoa ma se togiga tupe. Vili atu i le telefoni 800-722-1471 (TTY: 800-842-5357). េសចកតជី ូនដណំ ឹងេនះ掶នព័ត៌掶ន架៉ ងស޶នំ។ ់ េសចកតីជូនដំណឹងេនះរបែហល ᾶ掶នព័ត៌掶ន架៉ ងសំ޶ន់អពំ ីទរមង់ ែបបបទ ឬζរ殶៉ បរង់ របសអ់ នក㾶មរយៈ Español (Spanish): Premera Blue Cross ។ របែហលᾶ掶ន ζលបរ េចិ ឆទសំ޶ន់េ俅កន ុងេសចកតជី ូន Este Aviso contiene información importante. Es posible que este aviso contenga información importante acerca de su solicitud o cobertura a ដណំ ងេនះ។ឹ អនករបែហលᾶរតវζរបេញូ ច ញសមត徶ពថ ដលក់ ណតំៃថ ់ ងᾶកច厶់ ស់ través de Premera Blue Cross. Es posible que haya fechas clave en este 侶侶 េដើមបីនងរកឹ 羶ទកζរ䮶侶ុ 殶៉ បរង់ សខ徶ពរបសុ ់អនក ឬរ厶កជ់ ំនួយេចញៃថល។ aviso. Es posible que deba tomar alguna medida antes de determinadas អនក掶នសទិ ធទទិ ួលព័ត掶នេ៌ នះ និងជំនួយេ俅កន ុង徶羶របស់អនកេ⮶យមនអសិ fechas para mantener su cobertura médica o ayuda con los costos. Usted លយេឡុ ើយ។ សូ មទូរស័ពទ 800-722-1471 (TTY: 800-842-5357)។ tiene derecho a recibir esta información y ayuda en su idioma sin costo alguno. Llame al 800-722-1471 (TTY: 800-842-5357).

ਪ ੰ ਜਾਬੀ (Punjabi): Tagalog (Tagalog): ਇਸ ਨ ੋ ਿਟਸ ਿਵਚ ਖਾਸ ਜਾਣਕਾਰੀ ਹੈ. ਇਸ ਨ ੋ ਿਟਸ ਿਵਚ Premera Blue Cross ਵਲ ƒ ਤੁਹਾਡੀ Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang paunawa na ito ay maaaring naglalaman ng mahalagang impormasyon ਕਵਰਜੇ ਅਤ ੇ ਅਰਜੀ ਬਾਰ ੇ ਮਹ ੱ ਤਵਪਰਨੂ ਜਾਣਕਾਰੀ ਹ ੋ ਸਕਦੀ ਹ ੈ . ਇਸ ਨ ੋ ਿਜਸ ਜਵਚ ਖਾਸ ਤਾਰੀਖਾ . tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng Premera Blue ਹੋ ਸਕਦੀਆਂ ਹਨ ਜੇਕਰ ਤਸੀੁ ਜਸਹਤ ਕਵਰਜੇ ਿਰੱ ਖਣੀ ਹਵੋ ੇ ਜਾ ਓਸ ਦੀ ਲਾਗਤ ਜਿਵੱ ਚ ਮਦਦ ਦੇ Cross. Maaaring may mga mahalagang petsa dito sa paunawa. Maaring ਇਛ ੱ ੁਕ ਹ ੋ ਤ拓 ਤਹਾਨ ੁ ੰ ੂ ਅ ੰ ਤਮ ਤਾਰੀਖ਼ ਤ ƒ ਪਿਹਲ拓 ਕੁੱ ਝ ਖਾਸ ਕਦਮ ਚੱ ਕਣ ੁ ਦੀ ਲੋੜ ਹ ੋ ਸਕਦੀ ਹ ੈ ,ਤੁਹਾਨੰ ੂ mangailangan ka na magsagawa ng hakbang sa ilang mga itinakdang ਮਫ਼ਤੁ ਿਵੱ ਚ ਤ ੇ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵ ੱ ਚ ਜਾਣਕਾਰੀ ਅਤ ੇ ਮਦਦ ਪਾਪਤ㘰 ਕਰਨ ਦਾ ਅਿਧਕਾਰ ਹੈ ,ਕਾਲ panahon upang mapanatili ang iyong pagsakop sa kalusugan o tulong na 800-722-1471 (TTY: 800-842-5357). walang gastos. May karapatan ka na makakuha ng ganitong impormasyon at tulong sa iyong wika ng walang gastos. Tumawag sa 800-722-1471 .(Farsi): (TTY: 800-842-5357) فارسی اين اعالميه حاوی اطالعات مھم ميباشد .اين اعالميه ممکن است حاوی اطالعات مھم درباره فرم :(ไทย (Thai تقاضا و يا پ وشش بيمه ای شما از طريق Premera Blue Cross باشد . به تاريخ ھای مھم در ั ประกาศนมข้ี ี ้อมลส ู ําคญ ั ประกาศนอาจม ้ี ีข ้อมลท ู ่ีส ําคญเก ั ่ียวกบการการสม ัครหร ั ือขอบเขตประกน اين اعالميه توجه نماييد .شما ممکن است برای حقظ پوشش بيمه تان يا کمک در پرداخت ھزينه . สขภาพของคุณผ ุาน ่ Premera Blue Cross และอาจมีก ําหนดการในประกาศนี ้ คณอาจจะต ุ ้อง ھای درمانی تان، به تاريخ ھای مشخصی برای انجام کارھای خاصی احتياج داشته باشيد شما حق اين را داريد که اين اطالعات و ک مک را به زبان خود به طور رايگان دريافت نماييد . برای کسب ี่ ดําเน ินการภายในกาหนดระยะเวลาท ํ ่ีแนนอนเพ ่ ่ือจะร ักษาการประกนส ัขภาพของค ุณหร ุ ือการช ่วยเหล ือท اطالعات با شماره 1471-722-800 (کاربران TTY تماس باشماره 5357-842-800) تماس มคี่้่าใชจาย คณม ุีิิ่ี้ัู้สทธทจะไดรบขอมลและความชวยเหล ่ ื้ีอนในภาษาของคณโดยไม ุ่มค ี่้่าใชจาย โทร برقرار نماييد . 800-722-1471 (TTY: 800-842-5357) Polskie (Polish): To og oszenie mo e zawiera wa ne informacje. To og oszenie mo e ł ż ć ż ł ż Український (Ukrainian): zawiera wa ne informacje odno nie Pa stwa wniosku lub zakresu ć ż ś ń Це повідомлення містить важливу інформацію. Це повідомлення świadczeń poprzez Premera Blue Cross. Prosimy zwrócic uwagę na може містити важливу інформацію про Ваше звернення щодо kluczowe daty, które mogą być zawarte w tym ogłoszeniu aby nie страхувального покриття через Premera Blue Cross. Зверніть увагу на przekroczyć terminów w przypadku utrzymania polisy ubezpieczeniowej lub ключові дати, які можуть бути вказані у цьому повідомленні. Існує pomocy zwi zanej z kosztami. Macie Pa stwo prawo do bezp atnej ą ń ł імовірність того, що Вам треба буде здійснити певні кроки у конкретні informacji we własnym języku. Zadzwońcie pod 800-722-1471 кінцеві строки для того, щоб зберегти Ваше медичне страхування або (TTY: 800-842-5357). отримати фінансову допомогу. У Вас є право на отримання цієї

інформації та допомоги безкоштовно на Вашій рідній мові. Дзвоніть за Português (Portuguese): номером телефону 800-722-1471 (TTY: 800-842-5357). Este aviso contém informações importantes. Este aviso poderá conter informações importantes a respeito de sua aplicação ou cobertura por meio Tiếng Việt (Vietnamese): do Premera Blue Cross. Poderão existir datas importantes neste aviso. Thông báo này cung cấp thông tin quan trọng. Thông báo này có thông Talvez seja necessário que você tome providências dentro de tin quan trọng về đơn xin tham gia hoặc hợp đồng bảo hiểm của quý vị qua determinados prazos para manter sua cobertura de saúde ou ajuda de chương trình Premera Blue Cross. Xin xem ngày quan trọng trong thông custos. Você tem o direito de obter esta informação e ajuda em seu idioma báo này. Quý vị có thể phải thực hiện theo thông báo đúng trong thời hạn e sem custos. Ligue para 800-722-1471 (TTY: 800-842-5357). để duy trì bảo hiểm sức khỏe hoặc được trợ giúp thêm về chi phí. Quý vị có quyền được biết thông tin này và được trợ giúp bằng ngôn ngữ của mình miễn phí. Xin gọi số 800-722-1471 (TTY: 800-842-5357).