In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
Coverage is subject to the terms, conditions, and limitations of the member's contract.
Outpatient short-term rehabilitation services included in capitation are reimbursed on a monthly basis and are, therefore, not eligible for fee-for-service reimbursement consideration. The services listed in Attachment A are reimbursed in capitation to outpatient short-term rehabilitation providers designated by the primary care physicians (PCPs) of Health Maintenance Organization (HMO) members who utilize their referred benefit and who are enrolled in one of the following:
Policy: 07.13.01h:Orthoptic/Pleoptic Training
Policy: 10.02.02i:Chiropractic Spinal and Extraspinal Manipulation Therapy
Policy: 10.03.01j:Physical Medicine, Rehabilitation, and Habilitation Services
Policy: 10.06.01k:Speech Therapy