Seton Health Plan - Utilization Management Program List - Effective ...
Seton Health Plan - Utilization Management Program List - Effective ... Seton Health Plan - Utilization Management Program List - Effective ...
Seton Health Plan - Utilization Management Program List - Effective 1/01/11 (updated 12/23/10)This program list does not guarantee payment. Please contact health plan to verify member eligibility and covered benefitsSHP EPNSHP EPN ExpandedSeton CHIPMAP (CBRACKFQ &CPENDSSI)Travis County/AustinCommunity HealthcareClinics (CCHC, COTHER) &Travis Co Residents w/FPIL
- Page 2 and 3: SHP EPNSHP EPN ExpandedSeton CHIPMA
- Page 4: ServicesSHP EPNSHP EPN ExpandedSeto
- Page 7: CPT codes & notes
- Page 10: CPT codes & notesIncludes CPT codes
<strong>Seton</strong> <strong>Health</strong> <strong>Plan</strong> - <strong>Utilization</strong> <strong>Management</strong> <strong>Program</strong> <strong>List</strong> - <strong>Effective</strong> 1/01/11 (updated 12/23/10)This program list does not guarantee payment. Please contact health plan to verify member eligibility and covered benefitsSHP EPNSHP EPN Expanded<strong>Seton</strong> CHIPMAP (CBRACKFQ &CPENDSSI)Travis County/AustinCommunity <strong>Health</strong>careClinics (CCHC, COTHER) &Travis Co Residents w/FPIL
SHP EPNSHP EPN Expanded<strong>Seton</strong> CHIPMAP (CBRACKFQ &CPENDSSI)Travis County/AustinCommunity <strong>Health</strong>careClinics (CCHC, COTHER) &Travis Co Residents w/FPIL
SHP EPNSHP EPN Expanded<strong>Seton</strong> CHIPMAP (CBRACKFQ &CPENDSSI)Travis County/AustinCommunity <strong>Health</strong>careClinics (CCHC, COTHER) &Travis Co Residents w/FPIL
ServicesSHP EPNSHP EPN Expanded<strong>Seton</strong> CHIPMAP (CBRACKFQ &CPENDSSI)Travis County/AustinCommunity <strong>Health</strong>careClinics (CCHC, COTHER) &Travis Co Residents w/FPIL
CPT codes & notesAmbulance/EMS srvc covered if pt. transported to hospitalReference member ID card for phone numberReference member ID card for phone numberReference member ID card for phone numberCHIP Prior auth requred - Medical issue contact Mediview;Behavioral <strong>Health</strong> Issue contact Tejas; EPN & EXP - whenreferred by in-network psychiatrist - Direct access up to 6 hours oftesting. All other referrals require prior authorization. CPT code:96101. 96102CPT 90870Lifetime max of 20 visits - MAP members onlyCertain procedures are covered, prior auth required in all cases11 county area FPIL > 251% not eligible for charity. IF < 250%in 10 county area (excluding Travis) Max benefit of 30 days ofcharity DME when discharged from SETON facility.See quantity limit gridE0618-E0619E0163-E0166; E0168E0202E0470-E0472E2100E0602-E0604E0575-E0585E0601E1800-E1840/ E0935B4034-B4036/B4150-B4156B9000-B9999E2000E0250-E0270/E0277-E0297/K0549-K0550E0550-E0562E1700E0424-E0500/E1353-E1390/E1405-E1406E0621-E0636E0193E0371-E0372E0180-E0187/E0194-E01995024XE0316E0600E0720-E0765E1050-E1298/K0001-K0014E2402
CPT codes & notes
CPT codes & notesIncludes CPT codes: 7440-74415Includes CPT codes: 76090-76092
CPT codes & notesIncludes CPT codes: 78000-79999CPT codes: 78300-78320; 78350-78399CPT codes: 78460-78465CPT codes: 78460-78465 78478-78480CPT codes: 78000-78099Includes CPT codes: 79000-79999at <strong>Seton</strong> facilityCPT codes: 74246-74249Only EPNX members have access to other contractedtherapy providers; EPN members must use <strong>Seton</strong>Network facilitiesAustin Bariatric Clinic 371-9885codes99201-9921578-9865 for South Austin Clinic5667 or
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