| Summary of Benefits and Coverage: What my NOVA Pathfinder Limited plan covers and what my out-of-pocket expenses are for covered and non-covered services. Coverage Period: 01/01/2021-12/31/2021 NOVA Pathfinder Limited: HDHP with HSA option Coverage for All Covered Members Plan Type: HSA | |
| The Summary of Benefits and Coverage document will help you choose a health plan. The document shows how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, call toll-free 1-833-444-NOVA (6682). For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, providers, or other underlined terms see the Glossary. You can view the glossary at https://mynovahealthcare.org/ or call toll-free at 1-833-444-NOVA (6682) |
| Important Questions | Answers | Why This Matters: |
| What is the overall deductible? (See Footnote [1]) | $5,000 per person / $10,000 per family through the preferred provider open network; (See Footnote [2])for non-preferred providers open network (See Footnote [3]) the maximum cost per individual/family is unavailable per calendar year. | Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. (See Footnote [4]). |
| Important Questions | Answers | Why This Matters: | |
| What is the deductible for this plan? | $5,000 per person / $10,000 per family through the preferred provider. Please see the definition of provider (See Footnote [5]) For the non-preferred provider (non-participating) the maximum cost per individual/family is unavailable per calendar year. Please see the definition of Non-preferred provider (See Footnote [6]) | The deductible is the most you could pay in a year for covered services. If you have other family members on this plan, their allowance combined with yours reduces the family deductible until the overall family deductible has been met. On the Family and Individual Plus 1 plan, all Members contribute to the plan deductible. | |
| What is not included in the deductible? | Premiums, balance billing (See Footnote [7]) charges, penalties for non-certification, and healthcare services this plan doesn’t cover. | Even though you pay these expenses, they don’t count toward the deductible. | |
| Will you pay less if you use a preferred provider? | Yes. For a list of preferred providers call (888) 266-4462. If your provider is not on our preferred provider’s list, we are happy to work with them to get them into our preferred provider’s list. | This plan uses a preferred provider network. You will pay less if you use a preferred provider. You will pay the most if you use a non-preferred provider’s open network. You may receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). (See Footnote 7) | |
| Do you need a referral/preauthorization to see a specialist? | Yes, a referral/preauthorization is required from your primary care provider to see a specialist. (This includes holistic/naturopathic providers.) | Your provider can refer you to see a specialist with a referral. (This includes holistic/naturopathic providers.) NOTE: If the specialist needs to provide additional services, then those services will also need a preauthorization. NOTE: If your provider includes holistic/naturopathic providers, their orders and referral may include “over-the-counter” supplements and essential oils. These may be covered as an allowed benefit if the Wellness treatments & Services guidelines are followed for coverage limits. |
| Important Questions | Answers | Why This Matters: |
| Are there services covered before you meet your deductible? | Yes. Preventive care & annual wellness visits are covered (See Footnote [8]) before you meet your deductible. Primary Care Annual Wellness Visit $150.00 for two yearly visits are covered starting after three months of membership up to $150.00 for each visit or one combined visit for a total of $300.00 annually. (See Footnote [9] & [10]) The additional cost over the $300.00 is applied toward the deductible and paid by Member. (See Footnote [11]) | This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services before you meet your deductible. See a list of examples in the section to the left for an annual wellness visit. For more information about your coverage, call 833-444-NOVA (6682) |
| Chiropractor Annual Wellness Visit If your chiropractor is your primary care provider and they perform a health and wellness visit, you can substitute these services for your benefit (See Footnote 8 & 10) $100.00 per three visits are covered starting after three months of membership up to $100.00 for each visit or one combined visit for a total of $300.00 annually (See Footnote 8 & 10) The additional cost over the $300.00 is applied toward the deductible and paid by the Member. | This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services before you meet your deductible. See a list of examples in the section to the left for an annual wellness visit. For more information about your coverage, call 833-444-NOVA (6682) | |
| Are there services covered before you meet your deductible? | Standard Diagnostic Tests: If you are not sure if the test or screening will be covered, please get a preauthorization. If your provider orders an EKG or other needed imaging (i.e., chest x-ray), these are covered as part of your annual wellness visit. For more complex tests that are over $75.00, it is a good idea to request a preauthorization, so you know your cost. (See Footnote [12]) | This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services before you meet your deductible. See a list of examples in the section to the left for the annual wellness visit. For more information about your coverage, call 833-444-NOVA (6682). |
| Are there services covered before you meet your deductible? | Annual Wellness Visit Laboratory Tests: This list contains examples of standard annual wellness visit lab tests that may be ordered: Complete Blood Count (CBC), Lipid, Comprehensive Metabolic Panel (CMP), Cholesterol panel, Urinalysis, Glucose blood sugar, hemoglobin A1c, prothrombin time with INR, C-Reactive Protein (CRP) (has-CRP), and thyroid function. There are other lab tests we will cover. If you are unsure if we cover a test not listed above as an annual wellness visit lab test, please call us. For any laboratory tests that are over $50.00 (See Footnote [13]) Please call us on how to combine annual wellness visit types because your OBGYN could be an annual wellness visit or a pediatric annual wellness visit, or a pediatric vision/hearing annual wellness visit. (See Footnote [14] & [15]) Laboratory tests are covered up to $50.00 (See Footnote [16] & [17]) for each lab paid separately to the laboratory and not applied to deductible, starting after three months of membership. | This plan covers some items and services even if you haven’t yet met the deductible amount, however, a copayment or coinsurance may apply. For example, this plan covers certain preventive services without and before you meet your deductible. See a list of examples in the section to the left for the annual wellness visit. For more information about your coverage, call 833-444-NOVA (6682). |
| All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. |
| Common Medical Event | Services You May Need | What You Will Pay Preferred Providers | What You Will Pay NON-Preferred providers | Limitations, Exceptions, & Other Important Information |
| If you visit a health care provider office or clinic | Primary care visit to treat an Injury or Illness | 0% coinsurance after the deductible has been met. (See Footnote [18]) | The Member may pay coinsurance, balance billing based on our Allowable fee schedule if the deductible has been met. The Member may still have a balance owed. (See Footnote [19]) | Your provider can refer you to see a specialist with a referral. (This includes holistic/naturopathic providers.) NOTE: If the specialist needs to provide additional services those services will need a preauthorization. NOTE: If your provider includes holistic/naturopathic providers, their orders and referral may include “over-the-counter” supplements and essential oils. These may be covered as an allowed benefit if the guidelines in the wellness treatments & services are followed for coverage limits. |
| If you visit a health care provider office or clinic | Chiropractic care | (See Footnote 18 & 20 ) | (See Footnote 19) | Your provider can refer you to see a specialist with a referral. (This includes holistic/naturopathic providers.) If the specialist needs to provide additional services, those services will need a preauthorization. NOTE: If your provider includes holistic/naturopathic providers, their orders and referral may include “over-the-counter” supplements and essential oils. These may be covered as an allowed benefit if the guidelines in the wellness treatments & services are followed for coverage limits. NOTE: Although you can use your wellness treatments & services benefits to see your Chiropractor without a preauthorization, It is suggested that the Member talks to the Nova benefit department on how to combine visit limits per injury in addition to your wellness treatments and services to increase visit limits. |
| If you visit a health care provider office or clinic | Specialist Office Visit | (See Footnote [20]) | The Member may pay coinsurance, balance billing based on our Allowable fee schedule if the deductible has been met. The Member may still have a balance owed. (See Footnote 19) | Your provider can refer you to see a specialist (includes holistic/naturopathic providers) with a referral. Please note if the specialist needs to provide additional services, however, those services will require a preauthorization. NOTE: If your provider includes holistic/naturopathic providers, their orders and referral may include “over-the-counter” supplements and essential oils. These may be covered as an allowed benefit if the guidelines in the wellness treatments & services are followed for coverage limits. |
| Annual Wellness Visits Understanding the annual wellness visits and how they apply towards your deductible: If the test is ordered has not been performed within the age-appropriate guidelines Before scheduling your procedure, you should know your screening/test category. You should obtain the pre-procedure diagnosis code (meaning the reason for the test/screening) from the provider’s scheduler or medical assistant. With this information, we can determine if the screening/test with this diagnosis (provided by the provider, scheduler, or medical assistant) is covered under the policy as preventive or diagnostic. If so, will the diagnosis be processed as preventive or diagnostic? If you are not sure if the test being ordered will be categorized as preventive or diagnostic, which can impact your potential cost, we suggest that before your test, you reach out to our benefits team and/or your provider to help you plan for the potential costs. Much of this starts with understanding the reason for your test. Is it preventive, such as a routine mammogram, colonoscopy, or prostate cancer/ colon cancer screening? Or is it diagnostic for evaluation reasons or treatment of an existing condition? Is the test being ordered for chronic disease management for ongoing conditions or evaluation and diagnosis of new health issues? Is the exam(s) and screenings/tests and/or immunizations required solely for employment, immigration, licenses, travel, or other types of insurance? If any of the above services are included in your annual wellness visit, you may be responsible for the service if your deductible has not been met. This is because your procedure will be diagnostic. You may want to ask; will the allowable amount be allocated toward my deductible? By having your provider get a pre-authorization we can help reduce costs by negotiating a single-use case with agreed-upon fees. Could my screening/test start as a preventive and become a diagnostic for evaluation reasons or treatment of an existing condition? If this occurs, a portion or all of that benefit could be the patient’s responsibility. We would evaluate the CPT/Diagnosis/Modifier combinations and medical history available using billing guidelines from CMS. |
| Common Medical Event | Services You May Need | What You Will Pay Preferred Providers | What You Will Pay NON-Preferred providers | Limitations, Exceptions, & Other Important Information |
| Annual Wellness Visits | Preventive care – Annual Wellness Exams are covered before you meet your deductible. | 0% coinsurance | See Limit and Exceptions. The Member may pay coinsurance, balance billing based on our Allowable fee schedule if the deductible has been met. The Member may still have a balance owed. (See Footnote [21]) | Yes. Preventive Care & Annual Wellness Visit (AWV) are covered, (See Footnote [22]) before you meet your deductible. Primary Care Annual Wellness Visit $150.00 for two yearly visits are covered starting after three months of membership up to $150.00 for each visit or one combined visit for a total of $300.00 annually. (See Footnote [23] & [24]) The additional cost over the $300.00 is applied toward the deductible and paid by the Member. (See Footnote [25]) Chiropractor Annual Wellness Visit If your chiropractor is your Primary Care Provider and they perform a health and wellness visit, you can substitute these services for your benefit. (See Footnote 22) $100.00 per three visits are covered starting after three months of membership up to $100.00 for each visit or one combined visit for a total of $300.00 annually. (See Footnote [26]) Additional costs over the $300.00 are applied toward the deductible and paid by the Member. Standard Diagnostic Tests If you are not sure if the test or screening will be covered, please get a preauthorization. If your provider orders an EKG or other needed x-rays (i.e., chest x-ray) these are covered as part of your annual wellness visit. For more complex tests that are over $75.00, it is a good idea to request a preauthorization, so you know your cost. Annual Wellness Visit Laboratory Tests This list contains examples of standard annual wellness Visit lab tests that may be ordered: Complete Blood Count (CBC), lipid, Comprehensive Metabolic Panel (CMP), Cholesterol Panel, Urinalysis, Glucose Blood Sugar, Hemoglobin A1c, Prothrombin time with INR, C-Reactive Protein (CRP) (HS-CRP), and Thyroid Function. There are other lab tests we will cover. If you are unsure if we would cover a lab test as part of an annual wellness visit, please ask us. Lab tests are covered up to $50.00 for each test. Testing facilities are paid directly, not applied to the deductible, starting after three. (See footnotes [27] & [28]) For any laboratory tests that are over $50.00 (See Footnote [29]) Please call us on how to combine primary care annual wellness visit types, because your OBGYN could be an annual wellness visit or a pediatric annual wellness visit, and a pediatric vision/hearing annual wellness visit. (See Footnote [30] & 27) |
| Preventive Care | Adult Immunization | Four Adult Immunizations are covered, prior to the deductible being met. (See Footnote [31]) 0% coinsurance after the deductible has been met. | (See Footnote [32]). | Annual Flu vaccine Tetanus-diphtheria.Shingles vaccine for ages 50 and older (two-dose series). Pneumococcal vaccine (PDF) two different vaccines; one time for ages 65 & older. You may have to pay for services that aren’t preventive. Ask your provider if the services needed a preauthorization. The list above is what your plan will currently pay for without a preauthorization. If the reimbursement policy for submitting receipts is not followed, the Member might be responsible for paying the full amount. (See Footnote [33]) |
| Preventive Care | Childhood Immunization | Standard Childhood Immunizations are covered prior to the deductible being met. (See Footnote [34]) 0% coinsurance after the deductible has been met. | See limit and exceptions. The Member may pay coinsurance, balance billing based on our Allowable fee schedule if the deductible has been met. The Member may still have a balance owed. | Standard childhood Immunizations are covered under the benefit prior to the deductible being met. See limit and exceptions for flu shots & age-appropriate recommended Immunizations. You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check with us on what your plan will pay for without a preauthorization. You may want to check your local or state agency because some vaccines are required before your child can go to daycare or school. If the reimbursement policy for submitting receipts is not followed, the Member might be responsible for paying the full amount. (See Footnote [35]) |
| Preventive Care | Laboratory tests | Limited coverage prior to the deductible being met for the annual wellness visit lab test 0% coinsurance after the deductible has been met. | See limit and exceptions. The Member may pay coinsurance, balance billing based on our Allowable fee schedule if the deductible has been met. The Member may still have a balance owed. | Annual wellness visits laboratory tests (See Footnote [36] & [37]) This list contains examples of standard annual wellness visit lab tests that may be ordered. Complete Blood Count (CBC), lipid, Comprehensive Metabolic Panel (CMP), cholesterol panel, urinalysis, Glucose Blood Sugar, Hemoglobin A1c, Prothrombin Time with INR, C-reactive protein (CRP) (h-CRP), and thyroid function. There are other lab tests we will cover. If you are unsure if we would cover the test as an annual wellness visit lab test, please ask us or request prior authorization. Lab tests are covered up to $50.00 (See Footnote 36 & 37 & 38) for each lab paid separately to the laboratory and not applied to the deductible starting after three months of membership. All Laboratory tests that are over $50.00 (See Footnote [38]) If the reimbursement policy for submitting receipts is not followed, the Member might be responsible for paying the full amount. (See Footnote 35 & 36 & 37) |
| Preventive Care | Screening | 0% coinsurance after the deductible has been met. (See Footnote [39]) | See limit and exceptions. The Member may pay coinsurance, balance billing based on our Allowable fee schedule if the deductible has been met. The Member may still have a balance owed. | Age-appropriate recommended screenings A few we can list here, preventive colonoscopy screening, bilateral mammography screening, cervical cancer screening (pap test), and male prostate cancer screening, are covered. You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive, then check what your plan will pay for. If the reimbursement policy for submitting receipts is not followed, the Member might be responsible for paying the full amount. (See Footnote 35 & 36 & 37) |
| Telemedicine | 24/7 Teladoc Telehealth service subscription | 0% coinsurance | 0% coinsurance | Included with your membership is 24/7 telephone conference access anywhere in the United States for general medicine by Teladoc Telehealth Services. (See Footnote [40] ) |
Health and Wellness Treatments & Services
“None of the services in this category can be reimbursed until the deductible has been met. You may combine any health and wellness treatments & services up to the limits below to reach the deductible:
| $ 2000.00 max benefit for Individual $ 4000.00 max benefit for Individual +1 $ 4000.00 max benefit for Family |
| Common Medical Event | Services You May Need | What You Will Pay Preferred Providers | What You Will Pay NON-Preferred providers | Limitations, Exceptions, & Other Important Information |
| Health, Wellness Treatments & Services | Chiropractic Care | 0% coinsurance after the deductible has been met. (See Footnote [41]) | If the deductible has been met, the member may still have a balance owed and will need to pay coinsurance balance billing based on our allowable fee schedule. (See Footnote [42]) | NOTE: You may combine any Service in the wellness treatments & services benefit package until the maximum limit has been met. Your chiropractic provider can refer you to see a specialist, which includes holistic/naturopathic providers. Please note if the specialist needs to provide additional services, those services will need a preauthorization. NOTE: If your provider includes holistic/naturopathic providers their orders and referral may include “over-the-counter” supplements and essential oils these may be covered as an allowed benefit if the guidelines in the wellness treatments and services are followed for coverage limits. NOTE: Although you can use your wellness treatments & services benefits to see your Chiropractor without a preauthorization, it is suggested that the member talks to the Nova Claims department on how to combine visit limits per injury in addition to your wellness treatments & services to increase visit limits. If the reimbursement policy for submitting receipts is not followed, the member may be responsible for paying the full amount. (See Footnote [43] & 48 & [44]) |
| Wellness Treatment Services | Massage therapy | (See Footnote 42) | (See Footnote 43) | NOTE: This Service can be combined with any other Service in the wellness treatments & services benefit package until the maximum limit has been met. If the reimbursement policy for submitting receipts is not followed, the member might be responsible for paying the full amount. (See Footnote 44 & 48) |
| Wellness Treatments & Services | Homeopathy providers | (See Footnote 42) | (See Footnote 43) | NOTE: This Service can be combined with any other Service in the wellness treatments & services benefit package until the maximum limit has been met. If the reimbursement policy for submitting receipts is not followed, the Member might be responsible for paying the full amount. (See Footnote 44 & 48) |
| Wellness Treatments & Services | Holistic providers | 0% coinsurance after the deductible has been met (See Footnote [45]) | The Member may pay coinsurance, balance billing based on our Allowable fee schedule if the deductible has been met. The Member may still have a balance owed. (See Footnote [46]) | NOTE: This Service can be combined with any other Service in the wellness treatments & services benefit package until the maximum limit has been met. If the reimbursement policy for submitting receipts is not followed, the Member might be responsible for paying the full amount. |
| Wellness Treatments & Services | Naturopathic providers | (See Footnote 46) | (See Footnote 47) | NOTE: This Service can be combined with any other Service in the wellness treatments & services benefit package until the maximum limit has been met. If the reimbursement policy for submitting receipts is not followed, the Member might be responsible for paying the full amount. (See Footnote 48) |
| Wellness Treatments & Services | Hearing tests & aids | (See Footnote 46) | (See Footnote 47) | NOTE: This Service can be combined with any other Service in the wellness treatments & services benefit package until the maximum limit has been met. If the reimbursement policy for submitting receipts is not followed, the Member might be responsible for paying the full amount. (See Footnote 48) |
| Wellness Treatments & Services | Acupuncture | (See Footnote 46) | (See Footnote 47) | NOTE: This Service can be combined with any other Service in the wellness treatments & services benefit package until the maximum limit has been met. If the reimbursement policy for submitting receipts is not followed, the Member might be responsible for paying the full amount. (See Footnote 48) |
| Wellness Treatments & Services | Supplements & Essential Oils* | 0% coinsurance After the deductible has been met. (See Footnote 46) | (See Footnote 47) | NOTE: This Service can be combined with any other Service in the wellness treatments & services benefit package until the maximum limit has been met. These are the plan limitations for this benefit category: No reimbursement will occur until the deductible has been met. Each month not more than three bottles of a 30-day supply of supplements from an approved manufacturer of supplements. No more than two bottles of essential oils per month per person (See Footnote [47]) It is important to note that not all supplements and essential oils are equal, nor will all of them be accepted. The supplements purchased should contain a USP dietary supplement verification program seal or mark. For essential oils, we have two approved manufacturers you can purchase from as they follow good manufacturing practices (CGMPs). dōTERRA Essential Oils and or Young Living Essential Oils. See reimbursement policy on our website for submitting receipts. (See Footnote 50) |
| Common Medical Events & Services | Services You May Need | What You Will Pay Preferred Providers | What You Will Pay NON-Preferred providers | Limitations, Exceptions, & Other Important Information |
| Weight Loss, Strength training Programs | Gym Membership | Reimbursed to the Member after 12 months of continuous membership* | Reimbursed to the Member after 12 months of continuous membership* | Includes standard Gym fitness programs, yoga studios, Pilates studios $200.00 toward yearly gym membership Individual*$400.00 toward yearly gym membership Individual+1/Family Must be a yearly membership and must complete one year of plan enrollment lessor of clause applies. |
| Vision Coverage | Routine Eye Care | $350.00 benefit per person on the plan | $350.00 benefit per person on the plan | Vision coverage $350.00 towards any vision service per year. $350.00 benefit per person on the plan. The benefit starts three months after the date of enrollment or the anniversary enrollment date of each year enrolled. This includes adult /child screenings/eye refraction for vision correction purposes. |
| Biological/Holistic Dental Care | Routine Dental Care Biological Dental Care / Holistic Dental Care | $1,000.00 max per individual per year | $1,000.00 max per individual per year | $1,000.00 max per individual per year Benefit starts three months after the date of enrollment or anniversary enrollment date of each year enrolled. |
| Common Medical Event | Services You May Need | What You Will Pay Preferred Providers | What You Will Pay NON-Preferred Providers | Limitations, Exceptions, & Other Important Information |
| Women’s Health Services | Pre-Natal Office Visits | 0% coinsurance after the deductible has been met. (See Footnote [48]) | The Member may pay coinsurance, balance billing based on our Allowable fee schedule if the deductible has been met. The Member may still have a balance owed. (See Footnote [49]) | You may have to pay for services that aren’t preventive or part of your delivery if you have not met your deductible and/or if the services fall outside of our pregnancy protocol. Ask your provider if the services needed are preventive or part of your delivery. Then check what your plan will pay for using the pregnancy protocol as a guideline. All services require a preauthorization and a provider order. See the preauthorization form for details on how to submit a complete request for surgery preauthorization. All Professional, Facility and Other Charges that will be billed as part of the surgery should be included in the preauthorization. All Preadmission Testing must be performed and included in the surgical procedure when possible. All surgeries must meet the definition of medically necessary based on Medicare/Medicaid and our guidelines. (See Footnote [50] & 69) |
| Women’s Health Services | Pregnancy, and Delivery | Childbirth/ Delivery Facility/ Professional Services | (See Footnote 65) | Nova Pathfinder Limited Healthcare allows for coverage based on pregnancy protocol for delivery, pre-and post-maternity services & facilities that provide the lowest risk to the expectant mother and the baby in the listed choices. This includes a certified hospital or birthing center, OBGYN/hospital delivery, and c-section. |
| Women’s Health Services | Pregnancy, Delivery and Newborn Care | Newborn Care | (See Footnote 65) | Newborns or newborns must be added to the plan within 30 days after birth under the family plan. If a member is on an individual +1 plan, they must upgrade to a family plan. |
| Women’s Health Services | If you are Breastfeeding and need a Breast pump | Breast Pump DME (Durable Medical Equipment) | (See Footnote 75 & 78) | Breast Pumps fall under DME (Durable Medical Equipment) and are limited to a maximum of $500.00 each calendar year. All DME require a preauthorization and a provider’s order. See the preauthorization form for details on how to submit a complete request for preauthorization for a Breast Pump. All DME must meet the definition of medically necessary based on Medicare and our guidelines. (See Footnote 77) |
| Women’s Health Services | Birth Control | 0% coinsurance After the deductible has been met. Prior (See Footnote 46) | All conventional methods of birth control outlined in the ACA, including all Food and Drug Administration (FDA)-approved contraceptive methods prescribed by a woman’s healthcare provider, including Barrier methods, like diaphragms, female condoms, and sponges are covered. Note: See reimbursement policy on our website for submitting receipts. (See Footnote [51]) |
Excluded Services & Other Covered Services:
| Common Medical Event | Services You May Need | What You Will Pay Preferred Providers | What You Will Pay NON-Preferred providers | Limitations, Exceptions, & Other Important Information |
| Laboratory, Diagnostic, or Imaging | Laboratory testing (blood work) | 0% coinsurance after the deductible has been met. (See Footnote [52]) | The Member may pay coinsurance, balance billing based on our Allowable fee schedule if the deductible has been met. The Member may still have a balance owed. (See Footnote [53]) | Excluding the laboratory tests below, Nova requires a preauthorization for lab tests where the billed amount is over $50.00. (See Footnote [54] & [55] & 44) This list contains examples of standard annual wellness visit lab tests that may be ordered. Complete Blood Count (CBC), lipid, Comprehensive Metabolic Panel (CMP), cholesterol panel, urinalysis, glucose blood sugar, hemoglobin A1c, prothrombin time with INR, C-reactive protein (CRP) (HS-CRP), and thyroid function. It is possible that other lab tests could still be covered. If you are unsure if we would cover a specific test as an annual wellness visit lab test, please contact us. (See Footnote [56]) If a preauthorization is not obtained prior to the services being rendered, the member is responsible for paying the full amount. |
| Laboratory, Diagnostic, or Imaging | Diagnostic test (X-Ray,) Imaging (CT/PET Scans, MRIs, Ultrasounds, etc.…) | 0% coinsurance after the deductible has been met. (See Footnote 51) | (See Footnote 52) | If a preauthorization is not obtained prior to the services being rendered, the Member is responsible for paying the full amount. All Diagnostic Tests must meet the definition of medically necessary based on Medicare/Medicaid and our guidelines. (See Footnote 53, 55 & 56) |
| Outpatient Surgery | Facility fee (e.g., ambulatory surgery center) includes all additional provider fees and services. | 0% coinsurance after the deductible has been met. (See Footnote 51) | (See Footnote 52) | All Outpatient Surgical Procedures require a preauthorization and a provider order. See the preauthorization form for details on how to submit a complete request for preauthorization for surgery. All professional, facility and other charges that will be billed as part of the surgery should be included in the preauthorization. All Preadmission Testing must be performed and included in the surgical procedure when possible. All surgeries must meet the definition of medically necessary based on Medicare/Medicaid and our guidelines. (See Footnote 59) |
| Outpatient Surgery | Additional physician/ surgeon fees | 0% coinsurance after the deductible has been met. (See Footnote 51) | The Member may pay coinsurance, balance billing based on our Allowable fee schedule if the deductible has been met. The Member may still have a balance owed. (See Footnote [57]) | The following must be included in the preauthorization request for surgery or procedure. All Outpatient Surgical Procedures require a preauthorization and a provider order. See the preauthorization form for details on how to submit a complete request for preauthorization for a surgery. All professional, facility and other charges that will be billed as part of the surgery should be included in the preauthorization. All Preadmission Testing must be performed and included in the surgical procedure when possible. All surgeries must meet the definition of medically necessary based on Medicare/Medicaid and our guidelines. (See Footnote 59) |
| If you need immediate medical attention | Emergency Room Care | 0% coinsurance after the deductible has been met. (See Footnote 61) | (See Footnote 58) | Once the patient has stabilized and is able, we ask that the patient notify the hospital that emergency room surgical procedures may require a preauthorization and a provider order. See the preauthorization form for details on how to submit a complete request for a surgery preauthorization. All Professional, Facility and Other Charges that will be billed as part of the emergency room care should be included in the preauthorization when possible. All emergency room care must meet the definition of medically necessary based on Medicare/Medicaid and our guidelines. (See Footnote [58] & 60) |
| If you need immediate medical attention | Emergency Medical Transportation | Limited coverage | Limited coverage | The current benefit is $300.00 towards a one-way trip. This is not paid prior to the deductible being met. Nova Pathfinder Limited Healthcare does not cover round trip emergency medical transportation. |
| If you need immediate medical attention | Urgent care | 0% coinsurance after the deductible has been met. (See Footnote 61) | (See Footnote 58) | Once the patient has stabilized, Nova Pathfinder Limited Healthcare asks that the patient notify the urgent care clinic that some urgent care surgical procedures require a preauthorization and a provider’s order. See the preauthorization form for details on how to submit a complete request for preauthorization. All Professional, Facility and Other Charges that will be billed as part of the urgent care should be included in the preauthorization. All surgeries must meet the definition of medically necessary based on Medicare/Medicaid and our guidelines. (See footnote 59). |
| If you have a Hospital Stay | Inpatient/ Observation Facility fee (e.g., hospital room includes diagnosis services) | 0% coinsurance after the deductible has been met. (See Footnote [59]) | The Member may pay coinsurance, balance billing based on our Allowable fee schedule if the deductible has been met. The Member may still have a balance owed. (See Footnote 62) | Once the patient has stabilized, Nova Pathfinder Limited Healthcare asks that the patient notify the hospital admissions department that all Inpatient stays and surgical procedures require a preauthorization and a provider order. See the preauthorization form for details on how to submit a complete request for preauthorization. All Professional, Facility and Other Charges that will be billed as part of the surgery should be included in the preauthorization. All Preadmission Testing must be performed and included in the surgical procedure when possible. All surgeries must meet the definition of medically necessary based on Medicare/Medicaid and our guidelines. (See Footnote 59) |
| If you have a Hospital Stay | Inpatient physician/ surgeon fees | 0% coinsurance after the deductible has been met. (See Footnote 64) | (See Footnote 62) | All Physician/Surgeon fees for outpatient surgical procedures require a preauthorization and a provider order. See the preauthorization form for details on how to submit a complete request for preauthorization. All professional, facility and other charges that will be billed as part of the surgery should be included in the preauthorization. All Preadmission Testing must be performed and included in the surgical procedure when possible. All surgeries must meet the definition of medically necessary based on Medicare/Medicaid and our guidelines. (See Footnote [60]) |
| Outpatient Services If you need Mental Health, Behavioral Health, or Substance Abuse Services | Mental health, behavioral health, or substance abuse services office visit | (See Footnote [61]) | (See Footnote 62) | All Office Visits for Outpatient Services do not require a referral however they do require a provider order and a preauthorization when additional services are requested. |
| Outpatient Services If you need Mental Health, Behavioral Health, or Substance Abuse Services | Facility fee (e.g., hospital room services, physician/ surgeon fees | (See Footnote 64) | (See Footnote 62) | Once the patient has stabilized, Nova Pathfinder Limited Healthcare asks that the patient notify the hospital admissions department that all inpatient stays and surgical procedures might require a preauthorization and a provider order. See the preauthorization form for details on how to submit a complete request for preauthorization for surgery. All Professional, Facility and Other Charges that will be billed as part of the surgery should be included in the preauthorization. All Preadmission Testing must be performed and included in the surgical procedure when possible. All surgeries must meet the definition of medically necessary based on Medicare/Medicaid and our guidelines. (See Footnote 63) |
| If you need help recovering or have other special health needs | “At Home” Home Health Care Services | (See Footnote 65) | (See Footnote 66) | “At Home” non-skilled home healthcare benefit of $50.00 per day for a maximum of 30 days. This is not paid until the deductible has been met. (See Footnote & [62]) Limited to 30 visits per calendar year (rehabilitation, outpatient habilitation, and home health services are each limited to separate visit limits each calendar year). All Home Health Care requires a preauthorization and a provider’s order. See the preauthorization form for details on how to submit a complete request for preauthorization. All services must meet the definition of medically necessary based on Medicare/Medicaid and our medical review board guidelines. (See Footnote 66 & [63]) |
| If you need Physical Therapy | Physical Therapy & Occupational Therapy Services | (See Footnote 65) | (See Footnote 66) | All Physical Therapy and Occupational Therapy or Speech Therapy services are not paid until the deductible has been met. (See Footnote 68) Limited to 30 combined visits per calendar year for physical therapy and occupational therapy services, and 30 visits per calendar year for speech therapy services. (rehabilitation, outpatient rehabilitation, and home health services are each limited to separate visit limits each calendar year). All “At Home” Skilled Home Health Care services must meet the definition of medically necessary based on Medicare/Medicaid and our medical review board guidelines. (See Footnote [64] & 72) |
| If you need help recovering or have other special health needs | “At Home” Home Health Care Services | (See Footnote 65) | (See Footnote 66) | “At Home” skilled home healthcare benefit is $50.00 per day for a maximum of 30 days. Not paid until the deductible has been met. (See Footnote 68) Limited to 30 visits per calendar year (rehabilitation, outpatient rehabilitation, and home health services are each limited to separate visit limits each calendar year). All “At Home” Skilled Home Health Care services require a preauthorization and a provider’s order. See the preauthorization form for details on how to submit a complete request for preauthorization. All “At Home” Skilled Home Health Care services must meet the definition of medically necessary based on Medicare/Medicaid and our medical review board guidelines. (See Footnote [65] & 72) |
| If you need help recovering or have other special health needs | Rehabilitation Services | 0% coinsurance after the deductible has been met. (See Footnote 73) | The Member may pay coinsurance, balance billing based on our allowable fee schedule if the deductible has been met. The Member may still have a balance owed. (See Footnote 74) | Outpatient Rehabilitation Services benefit is $50.00 per day for a maximum of 30 days and is limited to 30 visits per calendar year. (Rehabilitative/habilitative home health services are each limited to separate visit limits each calendar year). All Outpatient Rehabilitation Services require a preauthorization and a provider’s order. See the preauthorization form for details on how to submit a complete request for preauthorization. All outpatient rehabilitation services must meet the definition of medically necessary. The “at home” outpatient rehabilitation services benefit is $50.00 per day for a maximum of 30 days. Not paid until the deductible has been met. (See Footnote [66]) Limited to 30 visits per calendar year (rehabilitation and outpatient habilitation home health services are each limited to separate visit limits each calendar year). All “At Home” Outpatient Rehabilitation services require a preauthorization and a provider order. See the preauthorization form for details on how to submit a complete request for preauthorization. All Outpatient Rehabilitation services must meet the definition of medically necessary based on Medicare/Medicaid and our medical review board guidelines. (See Footnote 70 & 71) |
| If you need help recovering or have other special health needs | Habilitation Services | (See Footnote [67]) | (See Footnote [68]) | The “At Home” Outpatient Habilitation services benefit is $50.00 per day for a maximum of 30 days and is limited to 30 visits per calendar year. (Rehabilitative/habilitative home health services are each limited to separate visit limits each calendar year). All Outpatient Habilitation Services require a preauthorization and a provider’s order. See the preauthorization for details on how to submit a complete request for preauthorization. All outpatient habilitation services must meet the definition of medically necessary based on Medicare and our guidelines. (See Footnote [69] & 78) |
| If you need help recovering or have other special health needs | Skilled Nursing Care | 0% coinsurance after the deductible has been met. (See Footnote [70]) | The Member may pay coinsurance, balance-billing based on our Allowablefeeschedule if the deductible has been met. The Member may still have a balance owed (See Footnote [71]) | There is a $175.00 per day for maximum of 30 days. This is limited to 30 visits per calendar year. (Rehabilitative/habilitative and skilled nursing care services are each limited to rehabilitation and skilled nursing care combined visit limits each calendar year). All Skilled Nursing Care Services require a preauthorization and a provider order. See the preauthorization form for details on how to submit a complete request for preauthorization. All skilled nursing care services must meet the definition of medically necessary based on Medicare and our guidelines. (See Footnote 75 & 78) |
| If you need help recovering or have other special health needs | Durable Medical Equipment (DME) | (See Footnote 76) | (See Footnote 77) | DME (Durable Medical Equipment) are limited to a maximum of $500.00 each calendar year. All DME require a preauthorization and a provider’s order. See the preauthorization form for details on how to submit a complete request for preauthorization for a surgery. All DME must meet the definition of medically necessary based on Medicare and our guidelines. (See Footnote 75 & [72]) |
| If you need help recovering or have other special health needs | 0% coinsurance after the deductible has been met. (See Footnote 76 ) | (See Footnote 77) | DME is limited to a maximum of $500.00 each calendar year. All DME require a preauthorization and a provider’s order. See the preauthorization form for details on how to submit a complete request for preauthorization for a surgery. All DME must meet the definition of medically necessary based on Medicare and our guidelines. (See Footnote 75 & 78) | |
| If you need help recovering or have other special health needs | Hospice Care Services | 0% coinsurance after the deductible has been met. (See Footnote 76) | The Member may pay coinsurance, balance billing based on our Allowable fee schedule if the deductible has been met. The Member may still have a balance owed. (See Footnote 81) | There is a $175.00 per day for maximum of 30 days. This is limited to 30 visits per calendar year. (Rehabilitative/habilitative and hospice care services are each limited to rehabilitation and skilled nursing care combined visit limits each calendar year). All hospice care services require a preauthorization and a provider’s order. See the preauthorization form for details on how to submit a complete request. All hospice care services must meet the definition of medically necessary based on Medicare and our guidelines. (See Footnote [73] & 78) |
| If your child needs eye care | Children’s Eye Exam & Children’s Glasses | (See Footnote 80) | (See Footnote 81) | Vision coverage provides $350.00 toward any Vision service per 12-month benefit period per person on the plan. |
| If your child needs dental | Children’s Dental Check-up | 0% coinsurance after the deductible has been met. (See Footnote [74]) | The Member may pay coinsurance, balance billing based on our Allowable fee schedule if the deductible has been met. The Member may still have a balance owed. (See Footnote [75]) | $1,000.00 max per individual per year per person on the plan. This is the Member’s child dental benefit. |
| Services your plan generally does NOT cover (This is not a complete list. Please see your plan document.) | ||
| Cosmetic surgery bariatric surgery (covered through the preferred provider network if medically necessary) | Infertility services Non-emergency care when traveling outside the U.S. | Private-duty nursing long-term care |
| Other covered services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) |
| Abortion services Hearing aidsRoutine foot care |
Health economics, pricing, benefits, preauthorization, and reimbursement information provided by Nova Healthcare are gathered from third-party sources and are subject to change without notice due to complex and frequently changing laws, regulations, rules, and policies. This information is presented for illustrative purposes only and does not constitute medical, reimbursement, or legal advice. Nova Healthcare encourages providers to submit accurate and appropriate requests for services and to submit accurate and appropriate requests for payment of claims for services. It is always the provider’s responsibility to determine medical necessity, the proper site for delivery of any services, and to submit appropriate codes, charges, and modifiers for services that are to be preauthorized and/or services to be rendered. Nova Healthcare recommends that you consult with any additional providers that will provide service to document additional preapprovals or reimbursements agreements. If there is a need to consult other reimbursement specialists and/or legal counsel regarding coding, coverage, and reimbursement matters. Nova Healthcare uses nThrive to determine the most appropriate reimbursement. The provider and facility will hold harmless Nova HealthCare against any claims outside of allowed and not allowed pricing requests when accepting to provide services to Nova Healthcare members. Nova Healthcare works with providers to avoid balance billing members. We strive to work with providers to pay reasonable, fair prices. The information included herein is current as of 09/20/2021 and is subject to change without notice.
FOR OFFICE USE ONLY:
The information contained in this document or facsimile message is confidential and intended only for the use of the individual(s) members or prospective members. Competitors of Nova Healthcare who find themselves in possession of this document should destroy or return the document to Nova Healthcare at accounts@mynovahealthcare.org. If the reader of this message is not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify us by telephone and destroy the facsimile. Please use a cover page prior to sending a fax to 805-375-6090.
[1] An amount you could owe during a coverage period (usually one year) for covered health care services before your plan begins to pay. An overall deductible applies to all or almost all covered items and services. A plan with an overall deductible may also have a separate deductible that applies to specific services or groups of services. In addition, a plan may have only a separate deductible. (For example, if your deductible is $5,000, your plan won’t pay anything until you’ve met your $5,000 deductible for covered health care services subject to the deductible.) The exception is health and wellness.
[2] Using an open-network preferred provider means the member will potentially pay the least amount when the provider accepts the fee schedule allowed amount and the not allowed amount. One example of a preferred provider is a provider who accepts the fee schedule rates Nova pays as the allowed amount for the service and normally will not balance bill the member. If the provider does balance bill it is an agreed-upon rate that the member is notified about prior to services because there is a preauthorization or a single case agreement in place for the services. A preferred provider needs a single case agreement to keep the members’ costs to a minimum. Nova always suggests that the member works with our claims and preauthorization teams shop the best price for the service to be provided. Be aware, your preferred provider network. might use a non-preferred provider’s open network for services such as lab tests. Check with Nova benefits department before you get services.
[3] Non-Preferred Providers are also considered part of the open network, considered a provider who doesn’t have a contract or will not accept a single case agreement or not accept the Nova fee schedule that is included in a preauthorization to provide services. If your plan covers non-preferred providers, you’ll usually pay more to see a non-preferred provider than a preferred provider. Nova also refers to these providers as “non-participating”.
[4] Members may request temporary assistance due to hardship and need to reduce the deductible requirements. This is granted on a case-by-case basis.
[5] Using an open-network preferred provider means the member will potentially pay the least amount. The Provider accepts the fee schedule allowed amount and not the allowed amount. One example of a preferred provider is a provider who accepts the fee schedule rates Nova pays as the allowed amount for the service and normally will not balance bill the Member. If the provider does balance bill, it is an agreed-upon rate, that the Member is notified about prior to services because there is a preauthorization or a single case agreement in place for the services. With a preferred provider that needs a single case agreement to keep the Member’s cost to a minimum. Nova always suggests that the Member works with our claims and preauthorization teams shop for the best price for the service to be provided. Be aware, your preferred provider network. might use a non-preferred provider open network for services such as lab tests. Check with the Nova benefits department before you get services.
[6] Non-Preferred Providers are also considered as part of the open network, considered a provider who doesn’t have a contract or will not accept a single case agreement or not accept the Nova fee schedule that is included in a preauthorization provide services. If your plan covers non-preferred providers, you’ll usually pay more to see a non-preferred provider than a preferred provider. Nova also refers to these providers as “non-participating”.
[7] When a provider bills you for the balance remaining on the bill that your plan doesn’t cover, this amount is the difference between the actual billed amount and the allowed amount. For example, if the provider charge is $200.00 and the allowed amount is $110.00, the provider may bill you for the remaining $90.00. This happens most often when you see a NON-preferred provider. An open network provider (preferred provider) might not bill the not allowed amount for the service.
[8] All services must be billed directly to the claims department on CMS-1500 or UB-04 or other approved claim form types for the services performed. Members are not to pay the provider at the time of service and submit receipts unless approved in advance.
[9] Paid to the provider of services after receiving an approved claim form.
[10] All paid fees are based on the allowed amount for CPT/diagnosis combinations using billing guidelines from Medicare and Medicaid.
[11] The Member must select to either use the primary care provider or to use their chiropractor for this benefit. The benefit cannot be combined with primary care annual wellness exams or chiropractor annual wellness exams. The Member has to select one service type to perform their preventive care.
[12] All Laboratory tests that are over $50.00 may require a yearly, multiple-year, or single-use preauthorization.
[13] All Laboratory tests that are over $50.00 may require a yearly, multiple-year, or single-use preauthorization.
[14] These can be combined with primary care annual wellness visits maximum benefit for combined visits is $300.00. An example would be one OBGYN annual wellness visit and one primary care annual wellness visit
[15] All paid fees are based on the allowed amount for CPT/diagnosis combinations using billing guidelines from Medicare and Medicaid for preventive care for OBGYN/pediatric and pediatric vision/hearing visits.
[16] All paid fees are based on the allowed amount for CPT/diagnosis combinations using billing guidelines from Medicare and Medicaid. Members pay the remainder of the lab charges not covered.
[17] Nova will cover annual wellness visit lab tests whose Medicare or Medicaid reimbursement rate is under $50.00 for each test ordered.
[18] 0% coinsurance after the deductible has been met.
[19] The Member may pay coinsurance, balance billing based on our Allowable fee schedule if the deductible has been met. The Member may still have a balance owed.
[20] 0% coinsurance after the deductible has been met.
[21] Members may pay coinsurance, balance billing based on our Allowable fee schedule if the deductible has been met. The member may still have a balance owed.
[22] All services must be billed directly to the claims department on CMS-1500 or UB-04 or other approved claim form types for the services performed. Members are not to pay the provider at the time of service and submit receipts unless approved in advance.
[23] Paid to the provider of services after receiving an approved claim form
[24] All paid fees are based on the allowed amount for CPT/diagnosis combinations using billing guidelines from Medicare and Medicaid.
[25] Member must select to either use the primary care provider or use their chiropractor for this benefit. The benefit cannot be combined with primary care annual wellness visits or chiropractor annual wellness visits, the member has to select one service type to perform their preventive care.
[26] All fees are based on the allowed amount for CPT/diagnosis combinations using billing guidelines for preventive care in chiropractic coding
[27] All paid fees are based on the allowed amount for CPT/Diagnosis combinations using billing guidelines from Medicare and Medicaid. Members pay the remainder of the lab charges not covered.
[28] Nova will cover annual wellness visit lab tests whose Medicare or Medicaid reimbursement rate is under $50.00 for each test ordered without preauthorization prior to the deductible being met.
[29] All laboratory test that is over $50.00 may require a yearly, multiple-year, or single-use preauthorization.
[30] Can be combined with primary care annual wellness visit maximum benefit for combined visits is $300.00. Examples would be one OBGYN annual wellness visit and one primary care annual wellness visit.
[31] All paid fees are based on the allowed amount for CPT/diagnosis combinations using billing guidelines from Medicare and Medicaid for preventive care for adult immunizations. Nova may have limits and exceptions to this benefit for travel and employment or duplicate immunization.
[32] Members may pay coinsurance, balance billing based on our Allowable fee schedule if the deductible has been met. The member may still have a balance owed.
[33] All provider-based services must be bill directly from the provider’s office for reimbursement on the proper claim form. See reimbursement policy for clarification of details.
[34] All paid fees are based on the allowed amount for CPT/diagnosis combinations using billing guidelines from Medicare and Medicaid for preventive care for adult immunizations. Nova may have limits and exceptions to this benefit for travel and employment or duplicate immunization.
[35] All provider-based services must be billed directly from the provider’s office for reimbursement on the proper claim form. See the reimbursement policy for clarification of details.
[36] All paid fees are based on the allowed amount for CPT/diagnosis combinations using billing guidelines from Medicare and Medicaid. Members pay the remainder of the lab charges not covered.
[37] Nova will cover annual wellness visit lab tests whose Medicare or Medicaid reimbursement rate is under $50.00 for each test ordered without preauthorization prior to the deductible being met.
[38] All Laboratory tests that are over $50.00 may require a yearly, multiple-year, or single-use pre-authorization.
[39] 0% coinsurance after the deductible has been met.
[40] Our Members have access to an amazing benefit, HealthiestYou. No more waiting at the doctor’s office for General Medical. See (Televideo) or talk to a doctor 24/7. Talk to a licensed doctor by phone or video from anywhere. Get an Expert Medical Opinion or get a second opinion from leading experts on more serious conditions.
[41] 0% coinsurance after the deductible has been met.
[42] If the deductible has been met, the member may still have a balance owed and will need to pay coinsurance balance billing based on our allowable fee scheduled.
[43] All provider-based services must be billed directly from the providers’ office for reimbursement on the proper claim form. See reimbursement policy for clarification of details.
[44] All provider-based services must be billed directly from the providers’ office for reimbursement on the proper claim form. See reimbursement policy for clarification of details.
[45] 0% coinsurance after the deductible has been met.
[46] Members may pay coinsurance, balance billing based on our Allowable fee schedule if the deductible has been met. The Member may still have a balance owed.
[47] Some essential oils will be considered one bottle per plan due to the nature of the oil. Please contact benefits to review a specific essential oil. The member will need to follow all reimbursement guidelines posted on our website to ensure the cost is credited to the deductible or if the deductible is met then reimbursed to the Member directly.
[48] 0% coinsurance after the deductible has been met.
[49] The Member may pay coinsurance, balance billing based on our allowable fee schedule if the deductible has been met. The Member may still have a balance owed
[50] All provider-based services must be billed directly from the provider’s office for reimbursement on the proper claim form. See the reimbursement policy for clarification of details.
[51] If the reimbursement policy for submitting receipts is not followed, the Member might be responsible for paying the full amount. The amount will not be applied to the deductible if the deductible is not met, if the deductible is met no reimbursement will be issued.
[52] 0% coinsurance after the deductible has been met.
[53] The Member may pay coinsurance, balance billing based on our Allowable fee schedule if the deductible has been met. The Member may still have a balance owed.
[54] All paid fees are based on the allowed amount for CPT/Diagnosis combinations using billing guidelines from Medicare and Medicaid. Members pay the remainder of the lab charges not covered.
[55] Nova will cover Annual Wellness Visit lab tests whose Medicare or Medicaid reimbursement rate is under $50.00 for each test ordered without preauthorization prior to the deductible being met.
[56] All Laboratory tests that are over $50.00 may require a yearly, multiple-year, or single-use preauthorization.
[57] The Member may pay coinsurance, balance billing based on our allowable fee schedule if the deductible has been met. The Member may still have a balance owed.
[58] All paid fees are based on the allowed amount for CPT/diagnosis combinations using billing guidelines from Medicare and Medicaid. Members pay the remainder of the lab charges not covered.
[59] 0% coinsurance after the deductible has been met.
[60] All provider-based services must be billed directly from the provider’s office for reimbursement on the proper claim form. See the reimbursement policy for clarification of details.
[61] 0% coinsurance after the deductible has been met.
[62] “At home” skilled home health care services include skilled nursing, physical therapy, speech therapy, and occupational therapy, etc. These are limited hours sessions.
[63] All paid fees are based on the allowed amount for CPT/diagnosis combinations using billing guidelines from Medicare and Medicaid. Members pay the remainder of the lab charges not covered.
[64] All provider-based services must be billed directly from the providers’ office for reimbursement on the proper claim form. See the reimbursement policy for clarification of details.
[65] All provider-based services must be billed directly from the providers’ office for reimbursement on the proper claim form. See the reimbursement policy for clarification of details.
[66]“At home” skilled home health care services include skilled nursing, physical therapy, speech therapy, and occupational therapy, etc. These are limited hours sessions.
[67] 0% coinsurance after the deductible has been met.
[68] The Member may pay coinsurance, balance billing based on our Allowable fee schedule if the deductible has been met. The Member may still have a balance owed.
[69] All provider-based services must be billed directly from the provider’s office for reimbursement on the proper claim form. See the reimbursement policy for clarification of details.
[70] 0% coinsurance after the deductible has been met.
[71] The Member may pay coinsurance, balance billing based on our Allowable fee schedule if the deductible has been met. The Member may still have a balance owed.
[72] All paid fees are based on the allowed amount for CPT/diagnosis combinations using billing guidelines from Medicare and Medicaid. Members pay the remainder of the lab charges not covered.
[73] All provider-based services must be billed directly from the provider’s office for reimbursement on the proper claim form. See the reimbursement policy for clarification of details.
[74] 0% coinsurance after the deductible has been met.
[75] The Member may pay coinsurance, balance billing based on our Allowable fee schedule if the deductible has been met. The Member may still have a balance owed.