Institutional Manual

Benefits, Exclusions and Limitations

CareFirst BlueCross BlueShield (CareFirst) and CareFirst BlueChoice, Inc. (CareFirst BlueChoice) offer a variety of benefit plans to meet our members' needs. These plans range from more traditional coverage to several managed care programs. Information regarding a member's specific benefit plan can be verified by:

• Using CareFirst Direct (click here for more information)
• Contacting Provider Services (see Important Telephone Numbers)

Please note, provision of services, even if medically necessary, by a participating provider or PPO provider does not, by itself, entitle a member to benefits if the services are excluded or do not otherwise meet the conditions and criteria for coverage.

Exclusions and Limitations

Each benefit program has limitations and exclusions applied to covered services. It is important to inquire about particular services that may be limited or excluded under the patient's coverage before rendering service so the patient can be informed of potential payment responsibility.

Information can be obtained electronically or by calling Provider Services(see Important Telephone Numbers). Because covered services can vary by benefit program and the member's group contract, a comprehensive list cannot be provided here. The following list indicates general exclusions applied to most benefit programs.

We will not provide benefits for:

• Any service, supply or item that is not medically necessary. Benefits will be provided for covered services only if the service is medically necessary, as determined by CareFirst.
• Experimental/investigational services as determined by CareFirst.
• Services that are not in accordance with accepted medical or psychiatric practices and standards in effect at the time the service is rendered, as determined by CareFirst.
• Services or supplies received at no charge to a member in a federal hospital; through any federal, state or local governmental agency or department; that are the legal obligation of the Member or where the charge is made only to insured persons. This exclusion does not apply to:

1. Medicaid;
2. Benefits provided in any state, county or municipal hospital;
3. Care received in a Veteran's hospital unless the care is rendered for a condition resulting from a Member's military service.

• Services not specifically indicated in the evidence of coverage as a covered service or that do not meet all other conditions and criteria for coverage, as determined by CareFirst.
• Routine, palliative or cosmetic foot care (except for conditions determined by CareFirst to be medically necessary), including: flat foot conditions, supportive devices for the foot, treatment of subluxations of the foot, care of corns, bunions. (except capsular or bone surgery), calluses, toe nails, fallen arches, weak feet, chronic foot strain and symptomatic complaints of the feet.
• Routine dental care. These services may be covered under a separate rider purchased by the Group and attached to the evidence of coverage.
• Cosmetic services (except for mastectomy-related services).
• Treatment rendered by a provider who is the member's parent, child, grandparent, grandchild, sister, brother, great grandparent, great grandchild, aunt, uncle, niece or nephew.
• Outpatient prescription drugs, unless otherwise stated in the evidence of coverage.
• All non-prescription drugs, medications, biologicals and over-the-counter disposable supplies, routinely obtained and self-administered by the member, except as stated in the evidence of coverage. Over-the-counter means any item or supply, as determined by CareFirst, that is available for purchase without a prescription, unless otherwise a covered service or allowed under Case Management, if applicable. This includes, but is not limited to: non-prescription eyewear, family planning and contraceptive products, cosmetics/ health and beauty aids, food/ nutritional items, support devices, non-medical items, foot care items, first aid and miscellaneous disposable or durable medical supplies, personal hygiene supplies, incontinence supplies, and over-the-counter medications and solutions.
• Any procedure or treatment designed to alter an individual's physical characteristics to those of the opposite sex.
• Lifestyle improvements, including, but not limited to: smoking cessation, health education classes and self-help programs, except as stated in the description of covered services.
• Fees or charges relating to: fitness programs, weight loss/ weight control programs, physical conditioning, exercise programs, physical conditioning, use of passive or patient-activated exercise equipment.
• Treatment for weight reduction and obesity, except for the surgical treatment of morbid obesity.
• Routine eyeglasses or contact lenses. These services may be covered under a separate rider purchased by the employer and attached to the evidence of coverage.
• Vision examination for prescribing or fitting eyeglasses or contact lenses. These services may be covered under a separate rider purchased by the group and attached to the evidence of coverage.
• Medical or surgical treatment of myopia or hyperopia.
• Radial keratotomy and any other forms of refractive keratoplasty, or any complications.
• Services furnished as a result of a referral prohibited by law.
• Services related to recreation activities, including, but not limited to: sports, games, equestrian activities and athletic training.
• Non-medical, provider services, including, but not limited to:

1. Telephone consultations
2. Charges for failure to keep a scheduled visit
3. Completion of forms
4. Copying charges
5. Other administrative services provided by the Health Care Provider or his/her staff.
6. Administrative fees charges by a Health Care Provider to a Member to retain the Health Care Provider's medical practices services (e.g., "concierge fees" or boutique medical practice membership fees). Benefits under this evidence of coverage are limited to covered services rendered to a member by a provider.

• Educational therapies intended to improve academic performance.
• Vocational rehabilitation and employment counseling.
• Services related to an excluded service (even if those services or supplies would otherwise be covered services) except general anesthesia & associated hospital or ambulatory surgical facility services for dental care.
• Separate billings for health care services or supplies furnished by an employee of a provider, which are normally included in the provider's charges and billed for by them.
• Services that are non-medical in nature, including, but not limited to, personal hygiene, cosmetic and convenience items, including, but not limited to, air conditioners, humidifiers, exercise equipment, elevators or ramps.
• Personal comfort items, even when used in an inpatient hospital setting, such as telephones, televisions, guest trays, or laundry charges.
• Custodial, personal or domiciliary care that is provided to meet the activities of daily living (e.g., bathing, toileting, eating and care that may be provided by persons without professional medical skills or training).
• Self-care or self-help training designed to enable a member to cope with a health problem or to modify behavior for improvement of general health (unless otherwise stated).
• Travel, whether or not advised by a health care practitioner. Please note, limited travel benefits related to an organ transplant may be covered under a separate rider purchased by the group and attached to the evidence of coverage.
• Services that do not fall within generally accepted standards of medical care and are intended to increase the intelligence quotient (IQ) of members with mental retardation or to provide cure for primary developmental disabilities.
• Services for the purpose of controlling or overcoming delinquent, criminal or socially unacceptable behavior.
• Milieu care or in vivo therapy: care given to change or control the environment, supervision to overcome or control socially unacceptable behavior, or supervised exposure of a phobic individual to the situation or environment to which an abnormal aversion is related.
• Dietary or nutritional counseling except as stated in the description of covered services, diabetes equipment, supplies and self-management training.
• Tinnitus maskers, purchase, examination or fitting of hearing aids except as stated in the description of covered services, hearing aids. Hearing care benefits for adult members may be covered under a separate rider purchased by the group and attached to the evidence of coverage.
• Services related to human reproduction, other than those specifically described in the evidence of coverage including, but not limited to, maternity services for surrogate motherhood or surrogate uterine insemination.
• Blood products and whole blood, when donated or replaced.
• Oral surgery, dentistry or dental processes, unless otherwise stated in the evidence of coverage.
• Treatment of temporal mandibular joint disorders, unless otherwise stated in the evidence of coverage.
• Premarital exams.
• Routine or periodic physical/ gynecological (GYN) exams or diagnostic services related to these exams, unless otherwise stated in the evidence of coverage.
• Services performed or prescribed by or under the direction of a person who is not a provider.
• Services performed or prescribed by or under the direction of a person who is acting beyond his/her scope of practice.
• Services provided through a dental or medical department of an employer, a mutual benefit association, a labor union, a trust, or a similar entity.
• Services rendered or available under any Worker's Compensation or occupational disease, or employer's liability law, or any other similar law, even if a member fails to claim benefits. Exclusions to these laws exist for partnerships, sole proprietorships and officers of closed corporations. If a member is exempt from the above laws, the benefits of this evidence of coverage will be provided for covered services.
• Services provided or available through an agent of a school system in response to the requirements of the Individuals With Disabilities Education Act and Amendments, or any similar state or federal legislation mandating direct services to disabled students within the educational system, even when such services are of the nature that they are Covered Services when provided outside the educational domain.
• Illnesses resulting from an act of war

Additional Exclusions Under HMO Benefit Programs
Services that are not covered under the HMO component may be considered for benefits under the Opt-Out Indemnity component, if applicable. Payment will not be made for:

• Reversal of vasectomies or tubal ligations
• Long-term rehabilitation or physical therapy
• Services which are primarily for custodial care. Custodial care is care that does not require the continuing attention of trained medical personnel. Services are considered custodial when they can be learned by an average individual who does not have medical training
• Sera (for example, for allergy treatment)
• Take home drugs from the hospital or other self-administered medications
• Hearing aids
• Care and treatment of the temporomandibular joint including TMJ pain syndrome
• Blood/concentrated red blood cells

Habilitative/Rehabilitative Services
In most instances CareFirst BlueChoice members must have physical, occupational and speech therapies performed in a professional provider's office setting and not in an institutional setting (unless it is considered medically necessary by CareFirst BlueChoice).

Laboratory/Radiology Services
CareFirst BlueChoice members and their specimens must be referred to Laboratory Corporation of America (LabCorp) for laboratory services. CareFirst BlueChoice members must be referred to a CareFirst BlueChoice contracted radiology facility for radiology services.

Mental Health
CareFirst BlueChoice members must visit mental health providers that contract directly with Magellan Behavioral Health.

Additional Exclusions Under Indemnity Benefit Programs
Hospitalization primarily for physical therapy or occupational therapy, unless therapy cannot be given on an outpatient basis, the complexity of the patient's condition requires additional skilled care and the member's contract includes a benefit for inpatient rehabilitation.

Additional Exclusions Under Limited Benefit Plan

• Infertility services, including testing, In vitro fertilization, ovum transplants and gamete intra-fallopian tube transfer, zygote intra-fallopian transfer, or cryogenic or other preservation techniques used in these or similar procedures.
• Services to reverse a voluntary sterilization procedure.
• Services for sterilization or reverse sterilization for a Dependent minor.
• Medical or surgical treatment for obesity, unless otherwise specified under "Covered Services".
• Medical or surgical treatment or regimen for reducing or controlling weight, unless otherwise specified under "Covered Services".
• Services incurred before the effective date of your coverage under this Certificate or Agreement
• Services incurred after your termination of coverage, including any extension of benefits
• Inpatient admissions primarily for diagnostic studies, unless authorized by CareFirst.
• Except for covered ambulance services, travel, whether or not recommended by a Health Care Practitioner.
• Except for Emergency Services, services received while you are outside the United States.
• Immunizations related to foreign travel.
• Accidents occurring while and as a result of chewing.
• Inpatient admissions primarily for physical therapy, unless authorized by CareFirst.
• Treatment of sexual dysfunction not related to organic disease.
• Organ transplants except those included as covered under Section 3.21.
• Non-human organs and their implantation.
• Wigs or cranial prosthesis.
• Weekend admission charges, except for emergencies and maternity, unless authorized by CareFirst.
• Outpatient orthomolecular therapy, including nutrients, vitamins, and food supplements.
• Services resulting from accidental bodily injuries arising out of a motor vehicle accident to the extent the services are payable under a medical expense payment provision of an automobile insurance policy.
• Services for conditions that State or local laws, regulation, ordinances, or similar provisions require to be provided in a public institution.
• Services for, or related to, the removal of an organ from a Member for purposes of transplantation into another person unless the transplant recipient is covered under this Certificate or Agreement and is undergoing a covered transplant, and the services are not payable by another health plan.
• Physical examinations required for obtaining or continuing employment, insurance, or government licensing.
• Private hospital room, unless authorized by CareFirst as Medically Necessary.
• Private duty nursing unless authorized by CareFirst.
• Treatment for mental health or substance abuse not authorized by CareFirst through our Utilization Management Program; or a mental health or substance abuse condition determined by CareFirst through our Utilization Management Program to be untreatable.

Additional Exclusions Under SEGO/MSGR

• In vitro fertilization, ovum transplants and gamete intra-fallopian tube transfer, zygote intra-fallopian transfer, or cryogenic or other preservation techniques used in these or similar procedures.
• Services to reverse a voluntary sterilization procedure.
• Services for sterilization or reverse sterilization for a dependent minor.
• Medical or surgical treatment for obesity, unless otherwise specified under "Covered Services".
• Medical or surgical treatment or regimen for reducing or controlling weight, unless otherwise specified under "Covered Services".
• Services incurred before the effective date of your coverage under this Certificate or Agreement
• Services incurred after your termination of coverage, including any extension of benefits
• Inpatient admissions primarily for diagnostic studies, unless authorized by CareFirst.
• Except for covered ambulance services, travel, whether or not recommended by a Health Care Practitioner.
• Except for Emergency Services, services received while you are outside the United States.
• Immunizations related to foreign travel.
• Accidents occurring while and as a result of chewing.
• Inpatient admissions primarily for physical therapy, unless authorized by CareFirst.
• Treatment of sexual dysfunction not related to organic disease.
• Organ transplants except those included as covered under Section 3.21.
• Non-human organs and their implantation.
• Wigs or cranial prosthesis.
• Weekend admission charges, except for emergencies and maternity, unless authorized by CareFirst.
• Outpatient orthomolecular therapy, including nutrients, vitamins, and food supplements.
• Services resulting from accidental bodily injuries arising out of a motor vehicle accident to the extent the services are payable under a medical expense payment provision of an automobile insurance policy.
• Services for conditions that State or local laws, regulation, ordinances, or similar provisions require to be provided in a public institution.
• Services for, or related to, the removal of an organ from a Member for purposes of transplantation into another person unless the transplant recipient is covered under this Certificate or Agreement and is undergoing a covered transplant, and the services are not payable by another health plan.
• Physical examinations required for obtaining or continuing employment, insurance, or government licensing.
• Private hospital room, unless authorized by CareFirst as Medically Necessary.
• Private duty nursing unless authorized by CareFirst.
• Treatment for mental health or substance abuse not authorized by CareFirst through our Utilization Management Program; or a mental health or substance abuse condition determined by CareFirst through our Utilization Management Program to be untreatable.

Care Management - Indemnity and HMO
CareFirst and CareFirst BlueChoice employ four criteria sets to guide our review process:

1. The Milliman Health Care Management Guidelines are a set of optimal clinical practice benchmarks for treating common conditions for patients without complications. These guidelines help provide the right care at the right time and in the right setting. The guidelines are not meant as a substitute for a physician's judgment about an individual patient.
2. Modified Appropriateness Evaluation Protocol (AEP) was originally developed at academic institutions in the Northeast. These criteria sets complement Milliman & Robertson, Inc.
3. The Apollo Managed Care criteria are utilized for physical therapy, occupational therapy and rehabilitation.
4. Magellan criteria for mental health and substance abuse review.

Criteria sets are evaluated annually and updated as needed to reflect current patterns of care. Because we recognize that standards of clinical practice may vary, all criteria sets are adopted, reviewed and modified as appropriate with the involvement and approval of practicing physicians.

For a copy of Milliman Health Care Management Guidelines, call 610-687-5644.

For an updated copy of the Modified AEP, the Magellan behavioral health and substance abuse criteria or how to order the Apollo Managed Care criteria, call 410-528-7041.

Care Management - Indemnity

Utilization Control Program (UCP)/Utilization Control Program Plus (UCP+)
These are inpatient admission review programs designed to contain hospital costs by reviewing admissions for appropriateness of the admission and number of inpatient days.

These programs feature admission review, continued stay review, retrospective review, and discharge planning.

These programs require that the CareFirst Care Management department be notified of admissions (see Important Telephone Numbers).

Coordinated Home Care and Home Hospice Care
Coordinated home care and home hospice care allows recovering and terminally-ill patients to stay at home and receive care in the most comfortable setting. For your patient to qualify for these benefits, the attending physician, hospital or home care coordinator must fax a treatment plan to CareFirst at 410-763-6462 or 410-763-7351. A licensed home health agency or approved hospice facility must render eligible services. Once approved, the home health agency or hospice is responsible for coordinating all services.

Individual Case Management (ICM)
Members with acute illnesses can voluntarily take advantage of ICM in a variety of specialty areas including AIDS, oncology, neonatology, pediatrics, high-risk obstetrics, head injury, spinal cord injury, medicine and surgery. ICM coordinates and supports services that help members attain short-term health objectives and long-term goals.

Health care providers or members may refer candidates for ICM (see Important Telephone Numbers).

Magellan Behavioral Health (Magellan)
Magellan offers a full array of managed behavioral health, substance abuse and Employee Assistance Programs (EAP) services, including utilization management, PPO, HMO and point-of-service networks. Magellan offers programs designed with a patient-advocacy focus such as Care Management and Enhanced Utilization Management.

Magellan's network-based clinical service program, care management, combines utilization management and the clinical skills and experience of a care management team to guide referrals and serve as a patient's advocate through the entire episode of care.

Enhanced Utilization Management is a utilization review process that works with each member's provider to ensure medically-necessary treatment in the most appropriate setting.

Services Requiring Authorization - CareFirst BlueChoice

• Acute inpatient hospitalization (medical, surgical or OB, which all include shock trauma)
• Skilled nursing facility
• Inpatient medical rehabilitation (physical, speech and occupational therapy)
• DME (durable medical equipment)
• Home health
• Ambulance (transport)
• Hospice (inpatient, outpatient, and home)
• Orthotics (including shoe orthotics; limited to certain benefit contracts)
• Prosthetics/orthopedic braces (limited to certain benefit contracts)
• Hearing aids/TMJ appliances (limited to certain benefit contracts)
• Outpatient hospital services
• Abortion services (limited to certain benefit contracts)
• Licensed birthing centers
• Lithotripsy
• Subacute Care
• Inpatient/outpatient behavioral health or substance abuse rehabilitation and acute medical detoxification requires certification by Magellan.
• Assisted reproductive technologies (IVF and artificial insemination)
• OB Observation (Labor and Delivery)

Inpatient Hospitalization Services - Indemnity and CareFirst BlueChoice

• Preadmission Certification Process for Elective Admissions
  • All elective inpatient hospital admissions must be authorized. The participating hospital personnel or the member, as it relates to their care, may request authorization. All participating hospitals must submit authorization through iExchange. For CareFirst BlueChoice members, all services must be approved by the PCP, who must concur that the proposed treatment plan is clinically appropriate.
  • Call in or fax the authorization request to the Care Management Department at least five business days prior to all elective admissions, except when it is not medically feasible due to the patient's medical condition. After hours or on weekends, a voice mail system will accept all pertinent information.
  • Unauthorized hospital stays will result in a retrospective review of the admission. Penalties may apply according to your contract.
  • A Utilization Review Analyst will certify an initial length of stay based on explicit criteria or forward the case to the nurse/supervisor for review upon receipt of an authorization request for preadmission.
  • Authorization decisions are made within two working days of obtaining necessary clinical information. Written authorization denials are issued within one business day of making the decision. Expedited or standard appeal information is included with the denial information.
  • If the admission date for an elective admission changes, notify the Care Management Department as soon as possible, and no later than one business day prior to the admission.
• Emergency Admission Certification Process
  • All emergency inpatient hospital admissions must be authorized within 48 hours of the admission or next business day. The PCP, admitting physician, hospital personnel or the member may request authorization.
  • Unauthorized hospital stays result in a retrospective review of the admission.
• Concurrent Review Process
  • Concurrent review is performed on most admissions. On-site hospital review may be performed at selected hospitals and on a case-by-case basis.
  • The hospital's Utilization Review Department must provide clinical information to CareFirst's or CareFirst BlueChoice's Utilization Management Nurse either on-site (at selected hospitals) or by telephone (see Important Telephone Numbers).
  • CareFirst's Utilization Management Nurse will contact the attending physician or follow agreed hospital protocol if further clarification of the member's status is necessary.
  • Utilization Management Nurses use approved medical criteria to determine medical necessity for acute hospital care.
  • If the clinical information meets our medical criteria, the days/services will be approved.
  • If the clinical information does not meet medical criteria, the case will be referred to our Medical Director.
  • The Utilization Management Nurse will notify the attending physician and the facility of our Medical Director's the decision.
  • The attending physician may request an appeal of an adverse decision.

Indemnity and HMO Retrospective Review Process
The Utilization Review nurse will notify the appropriate hospital department and request medical records when a retrospective review of the clinical record is necessary.

Discharge Planning Process - Indemnity and HMO

The hospital or attending physician must initiate a discharge plan as a component of the patient's treatment plan. The hospital, under the direction of the attending physician, should coordinate and discuss an effective and safe discharge plan with us and each patient immediately following admission. Discharge needs should be assessed and a discharge plan developed prior to admission, when possible. Referrals to hospital social workers, long-term care planners, discharge planners or hospital case managers should be made promptly after admission and coordinated with us.

Outpatient Hospitalization Services

Indemnity and HMO Certification Process
CareFirst BlueChoice requires preauthorization for all hospital outpatient services.

Indemnity preauthorization requirements are dependent on the contract and can be found on the back of the member's identification card.

Case Management Referral Process - Indemnity and HMO

Case Management is designed to identify patients who require more involved coordination of care due to a catastrophic, chronic, progressive or high risk acute illness. Case Managers coordinate and plan the patient's use of health care benefits and care without compromising quality of care. Patients who would benefit from these services should be referred as soon as they are identified (see Important Telephone Numbers).

Case Management intervention is appropriate for patients

• with catastrophic, progressive, chronic, or life-threatening diseases.
• who will require inpatient or extensive outpatient rehabilitation when medically stable.
• who require continuing care due to a catastrophic event or an acute exacerbation of a chronic illness.
• with extended acute care hospitalizations.
• with repeat hospital admissions within a limited time period.

Case Managers prepare and coordinate care plans in collaboration with physicians, providers, patients and families. Case Managers ensure that care plans are covered under patients' existing benefits.

To maximize the advantages of Case Management, it is closely aligned with other components of the managed care program such as preauthorization, concurrent review and discharge planning.

Disease Management Programs
Disease Management provides members with educational resources and reminders necessary for managing their chronic conditions in conjunction with their provider's plan of care, reducing the disease's effect through lifestyle changes and treatment compliance. Disease Management programs are offered for members with:

• Respiratory Diseases (i.e., asthma, COPD)
• Diabetes
• Heart Disease
• Oncology

For claim status, call BlueLine, FirstLine or log on to CareFirst Direct (click here for more information on CareFirst Direct). Members should contact their Blue Cross and Blue Shield Plan with claim status or payment inquiries. Refer them to their ID card for a customer service number.