The provisions for Advanced Radiological Imaging services listed below apply to all BlueCross BlueShield of Tennessee PPO and Copay PPO Plans:
PPO – Benefits are provided at deductible and coinsurance.
Copay PPO - Copay will apply when services are received from a network Provider. Out-of-network services are reimbursed at deductible and coinsurance.
Amount of copay varies by Plan ($50.00 - $200.00 per in-network procedure). Guidelines
The Advanced Radiological Imaging copay should be waived if the tests are performed during a Covered admission. The hospital inpatient copay should be taken.
For a Copay PPO Member health care benefits plan, where the Member has copay per Emergency Room visit and an Advanced Radiological Imaging service is performed in conjunction with the ER visit, the Advanced Radiological Imaging copay should be waived; only the ER copay should be taken. For a PPO Member health care benefits plan, benefits are provided at deductible and coinsurance.
When outpatient surgery has a copay per service and an Advanced Radiological Imaging service is performed in conjunction with the outpatient surgery, both the outpatient surgery and Advanced Radiological Imaging copay will apply.
When an office visit has copay per visit and an Advanced Radiological Imaging
procedure is performed in conjunction with the office visit, both the office copay and the Advanced Radiological Imaging diagnostic copay will apply.
If other services that have an assigned copay such as therapy services, ambulance services, periodic health assessment and durable medical equipment are performed, the Advanced Radiological Imaging copay should be taken in addition to all other copays for the services mentioned above.
If the service is provided at a facility, the copay is taken on the facility claim. The facility where the Member presents for care should collect the Advanced Radiological Imaging copay.
If the Member receives two or more procedures, the Advanced Radiological Imaging copay will apply on each separate procedure.
The following grid is intended to assist Providers in determining when Member copay for Advanced Radiological Imaging services is appropriate:
Member copay for advanced radiological imaging services is appropriate when:
Situation Rule Facility Claim Professional Claim
The Member has inpatient hospital copay.
An Advanced Radiological Imaging service is performed during a covered inpatient admission.
Inpatient copay per admission is inclusive. Take only the inpatient hospital copay.
Do not take copay for Advanced Radiological Imaging charges.
Do not take copay for Advanced
Radiological Imaging charges.
The Member has ER copay. An Advanced Radiological Imaging service is performed in conjunction with ER visit.
Take the ER copay only for Copay PPO Plans. PPO Plan will pay at deductible and coinsurance.
Do not take
copay for Advanced Radiological Imaging services. PPO Provider will bill Member for applicable deductible and
coinsurance amounts.
Do not take copay for Advanced
Radiological Imaging charges. PPO Provider will bill Member for
applicable deductible and coinsurance amounts. The Member has Outpatient
Surgery copay per service. An Advanced Radiological Imaging service in
conjunction with the outpatient surgery.
Take both the Outpatient Surgery copay and the
Advanced Radiological Imaging procedure copay.
Take the copay. Do not take copay for Advanced
Radiological Imaging charges.
The Member has office visit copay.
An Advanced Radiological Imaging procedure is
performed in conjunction with the office visit.
Take both the office visit and the Advanced Radiological Imaging copay.
N/A - No facility charge should be billed.
Take copay for Advanced
Radiological Imaging charges and office visit copay when performed in Practitioner’s office. Any Advanced Radiological
Imaging service billed as global.
Take copay on “global” fee only.
N/A N/A
Member has traditional PPO Plan without copay or with office visit copay but deductible and coinsurance for other services.
Applicable deductible and coinsurance apply.
Take the deductible and coinsurance amount.
Take the deductible and coinsurance amount.
Note: Advanced Radiological Imaging services are defined as CT Scans, MRIs, MRAs, PET scans, nuclear medicine and other similar technologies.
Drugs
Medically Necessary and Medically Appropriate pharmaceuticals for the treatment of disease or injury. (See Provider-Administered Specialty Pharmacy Medications and Diabetes Treatment later this section and also Section XIX. Pharmacy, in this Manual for more pharmacy specifics.)
Covered –
Benefits for the treatment of Phenylketonuria (PKU), including special dietary formulas while under the supervision of a Practitioner; and
Pharmaceuticals that are dispensed or intended for use while the Member is confined in a hospital, skilled nursing facility or other similar facility.
Exclusions include, but are not limited to –
Except as specified or covered by a supplemental Rider, the Member’s health care benefits plan does not provide coverage for prescription drugs except as indicated above; and
Those pharmaceuticals that may be purchased without a prescription.
Durable Medical Equipment
Medically Necessary and Medically Appropriate medical equipment or items that: (1) in the absence of illness or injury, are of no medical or other value to the Member; (2) can withstand repeated use in an ambulatory or home setting; (3) require the prescription of a Practitioner for purchase; (4) are approved by the FDA for the illness or injury for which it is prescribed; and (5) are not solely for the Member’s convenience.
Covered –
Rental of Durable Medical Equipment - Maximum allowable rental charge not to exceed the total Maximum Allowable Charge for purchase;
The repair, adjustment or replacement of components and accessories necessary for the effective functioning of covered equipment;
Supplies and accessories necessary for the effective functioning of Covered Durable Medical Equipment; and
The replacement of items needed as the result of normal wear and tear, defects or obsolence and aging. Insulin pump replacement is Covered only for pumps older than 48 months and only if the pump cannot be repaired.
Exclusions include, but are not limited to –
Charges exceeding the total cost of the Maximum Allowable Charge to purchase the equipment;
Unnecessary repair, adjustment or replacement or duplicates of any such equipment;
Supplies and accessories that are not necessary for the effective functioning of the covered equipment;
Items to replace those, which were lost, damaged, stolen or prescribed as a result of new technology except when the new technology is replacing items as a result of normal wear and tear, defects or obsolescence and aging;
Items that require or are dependent on alteration of home, workplace or transportation vehicle;
Motorized scooters, exercise equipment, hot tubs, pools, and saunas;
“Deluxe” or “enhanced” equipment. In all instances, the most basic equipment that will provide the needed medical care will determine the benefit;
Computerized or gyroscopic mobility systems, roll about chairs, geriatric chairs, hip chairs, and seat lifts of any kind;
Patient lifts, auto tilt chairs, air fluidized beds, or air floatation beds, unless approved by Case Management for a Member who is in Case Management; and
Portable ramp for a wheelchair. Rev 03/15