Coverage Policies

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Charges by physicians for participation in care management team conferences are generally considered to be included in the other services rendered relating to that care, and are not separately reimbursable. Charges by physicians for care plan oversight services will be reimbursed, when considered to be medically necessary.

1)    Care plan oversight services are significant services rendered by a physician to oversee and coordinate the complex care requirements of some patients confined at home, enrolled in hospice, or in a nursing facility. These charges are subject to audit.

2)    Team conferences are considered to be a part of the routine care provided by physicians, other caregivers, and facilities to patients confined in acute, subacute and rehabilitation facilities.

Codes Used In This BI:

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD,  EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.