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Health Coverage Information
Guidelines for Determining Coverage | Clinical Policy Bulletins | Medicare | Payment Policy | Dispute Process
Medical Get easy access to information that helps you understand what may or may not be covered by your patients' health insurance or health benefits plans; read up on the reasoning behind the decisions. Guidelines for Determining Coverage Review evidence-based clinical guidelines from nationally recognized authorities. Understand how they guide our staff in making decisions about precertification, inpatient review, discharge planning and retrospective review.  morePrecertification List Get the most up-to-date list to see if particular service, procedure, prescription drug or medical device needs precertification. Review a printable list or search by code. more
Clinical Policy Bulletins (CPBs) Learn more about our policies on the status and medical necessity of emerging medical technologies and services - and how we make appropriate coverage decisions - through our CPBs. more
Medicare The Medicare Advantage Private Fee-For-Service (PFFS) plan provides all of the benefits covered under Original Medicare plan and more, such as unlimited hospitalization and full coverage of preventive services. more
Payment Policy Learn more about our claim payment policies and processes. more
Dispute Process This is the process for practitioners and organizational providers to dispute an adverse decision. This includes when and how to submit a dispute. more
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* The term precertification here means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company's clinical criteria for coverage. It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members. |
