9. DESARROLLO DE MODELOS PARA LA MEJORA DE LA EFICIENCIA ENERGÉTICA EN LA
10.1. Modelos para el diseño de la conducción óptima
Inpatient and/or outpatient professional services.
Intensive medical care rendered to a member whose condition requires a physician's constant attendance and treatment for a prolonged period of time.
Medical care rendered concurrently with surgery during the hospital stay by a physician other than the operating surgeon for treatment of a medical condition separate from the condition for which the surgery was performed. Medical care by two or more physicians rendered concurrently during the hospital stay when the nature or
severity of the member’s condition requires the skills of separate physicians.
Consultation services rendered by another physician at the request of the attending physician, other than staff consultations which are required by hospital rules and regulations.
Home, office and other outpatient medical care visits for examination and treatment of the member.
Other Services
Provider requested HLA testing, donor searches and/or a harvest or storage of stem cells prior to the final determination as to what transplant procedure will be requested. Under these circumstances, the HLA testing and donor search charges are covered as diagnostic services. If coverage is provided for HLA testing, donor searches, and/or a harvest and storage it is not an approval for the subsequent requested transplant. A separate medical necessity determination will be made to the transplant procedure.
Immunosuppressant drugs prescribed for outpatient use in connection with a covered human organ and tissue transplant that are dispensed only by written prescription and that are approved for general use by the Food and Drug Administration, but only if your coverage has a prescription drug benefit.
Anthem will provide assistance with reasonable and necessary travel expenses as determined by Anthem, when you receive prior approval and are required to travel more than 75 miles from your residence to reach the facility where your covered transplant procedure will be performed. Anthem’s assistance with travel expenses includes transportation to and from the covered facility and lodging for the covered member and one companion. If the member receiving the treatment is a minor, then reasonable and necessary expenses for transportation and lodging may be allowed for two companions. You must submit itemized receipts for transportation and lodging expenses in a form satisfactory to Anthem when claims are filed. You may contact Anthem for detailed information. No benefits will be paid until after the transplant services are received. For lodging and ground transportation benefits, Anthem will provide a maximum benefit up to the current limits set forth in the Internal Revenue Code.
As used in this section, the term donor means a person who furnishes organ tissue for transplantation. If a human organ or tissue transplant is provided from a donor to a transplant recipient, the following apply:
When both the recipient and the donor are Anthem members, each is entitled to the Covered services specified in this section.
Member Benefits
The donor benefits are limited to those not provided or available to the donor from any other source. This includes, but is not limited to, other insurance coverage, grants, foundations, government programs, etc.
If the donor is Anthems member, and the recipient is not covered by Anthem, benefits will not be provided for the donor or recipient expenses.
Coverage includes covered services related to the live donor and/or donated organ or tissue, such as hospital, surgical, medical, storage and transportation costs (including complications from the donor procedure for up to 6 weeks from the date of procurement).
No benefits will be provided for procurement of a donor organ or organ tissue which is not used in a covered transplant procedure, unless the transplant is cancelled due to the member’s medical condition or death and the organ cannot be transplanted to another person. No benefits will be provided for procurement of a donor organ or organ tissue which has been sold rather than donated.
Only those organ and tissue transplants and directly related procedures specified in this section are covered services under this benefit booklet.
Transplant Benefit Period
The Transplant Benefit Period starts one day prior to a covered transplant procedure and lasts for the applicable case rate / global time period. The number of days will vary depending on the type of transplant received and the Provider agreement. Call the case manager for specific In-Network transplant Provider details for services received at or coordinated by an In-Network transplant Provider facility. At the end of the case rate / global time period, benefit are provided under other sections of the benefit booklet, depending on where the service is performed and are not subject to the terms of this section.
Human Organ and Tissue Transplant Exclusions
—
The following services, supplies or care are not covered: Benefits for services performed at any hospital which is not designated or approved by Anthem to providehuman organ and tissue transplant services for the organ or tissue being transplanted.
Benefits for services if the member is not a suitable candidate as determined by the hospital designated and approved by Anthem to provide such services.
Benefits for services for donor searches or tissue matching, or personal living expenses related to donor searches or tissue matching, for the recipient or donor, or their respective family or friends.
Any experimental or investigational transplant, treatment, procedure, facility, equipment, drug, device, service, or supply. Any service or supply associated with or provided in follow-up to any of the above.
Any transplant, treatment, procedure, facility, equipment, drug, device, service, or supply that requires Federal or other governmental agency approval and such approval is not granted at the time services are provided. Any service or supply associated with or provided in follow-up to any of the above.
Transplants of organs other than those listed above, including non-human organs. Procurement of a donor organ which has been sold rather than donated.
Related to artificial and/or mechanical hearts or for subsequent services and supplies for a heart condition as long as any of the artificial or mechanical heart remains in place. This exclusion includes services for implantation, removal and complications.
Personal comfort and convenience items such as televisions, telephone, articles for personal hygiene and other similar services and supplies.
For non-covered transportation and lodging expenses related but not limited to the following: - Alcohol, tobacco, other non-food items.
- Meals. - Child care.
- Mileage within the medical transplant facility city.
- Rental car, buses, taxis, or shuttle services, except as specifically approved by Anthem. - Frequent Flyer miles.
- Coupons, vouchers, or travel tickets. - Prepayment or deposits.
- Services for a condition that is not directly related, or a direct result, of the transplant. - Telephone calls.
Member Benefits
- Laundry. - Postage. - Entertainment.
- Interim visits to a medical care facility while waiting for the actual transplant procedure. - Travel expenses for donor companion/caregiver.
- Return visits for the donor for a treatment of a condition found during the evaluation.