Medical Policies
Although your Benefit Booklet (PDF, 715KB) provides a good overview of what services and products were available to you under the Indemnity plan, the medical policies below provide detailed information around the circumstances under which certain services and products were and were not covered.
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| Medical Policy Name | Number |
|---|---|
| Acupuncture | ME0005 |
| Medical and Pharmacy Appeal and Grievances |
AD0050 |
| Ambulance |
AH0020 |
| Anesthesia |
SU0025 |
| Biofeedback |
ME0075 |
| Blood (Whole, Components & Derivatives) |
ME0095 |
| Breast Magnetic Resonance Imaging (MRI) |
RA0201 |
| CT and CTA |
RA0203 |
| Cardiac Rehabilitation |
AD0150 |
| Cataract Lenses For Aphakia Persons |
ME0105 |
| Chiropractic Services |
AD0170 |
| Claims Research And Refund Requests |
AD0680 |
| Contraceptives |
ME0200 |
| CPAP/BIPAP/DPAP |
AH0125 |
| Crisis Evaluation and Stabilization Services |
IN0560 |
| Custodial Care |
IN0250 |
| Dental & Oral Surgical Services |
SU0160 |
| Dietary Supplements |
AD0200 |
| Durable Medical Equipment |
AH0200 |
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| Medical Policy Name | Number |
|---|---|
| Electroconvulsive Therapy (ECT) |
IN0300 |
| Emergency Room Services |
AD0225 |
| Equipment For Surgical Or Diagnostic Procedures |
AD0230 |
| Excision Of Gynecomastia |
SU0185 |
| Experimental/Investigational Procedures |
SU0190 |
| Freestanding Birth Center |
AD0300 |
| Home Care |
AH0355 |
| Hospice Care |
AD0330 |
| Hospital Inpatient Services |
AD0335 |
| Hospital Outpatient Services |
AD0340 |
| Hyperalimentation (Total Parenteral Nutrition) | AH0375 |
| Immunizations | AD0350 |
| Infertility | ME0475 |
| Inpatient Medical Detoxification For Chemical Dependency | AD0420 |
| Inpatient Psychiatric/Chemical Dependency Care | IN0450 |
| Inpatient Rehabilitation Facility Benefits | IN0660 |
| Keloids | SU0250 |
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| Medical Policy Name | Number |
|---|---|
| Lateral Electrical Surface Stimulation (LESS) | SU0275 |
| Male Potency Evaluation | ME0550 |
| Mammoplasties | SU0300 |
| Medically Necessary | AD0125 |
| Medical Photography | AD0425 |
| Medical Supplies | AH0600 |
| Mental Health/Chemical Depend Appeals Process | AD0100 |
| Mental Health/Chemical Dependency Case Management | AD0430 |
| Myotherapy | ME0580 |
| Obstetrics | SU0375 |
| Orthognathic Surgery | SU0410 |
| Out Of State UCR | AD0480 |
| Outpatient Diabetes Self Care Program | AD0485 |
| Outpatient Psychotherapy | ME0650 |
| Outpatient Treatment/Intensive OP Program (IOP) | ME0495 |
| Oxygen | AH0650 |
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| Medical Policy Name | Number |
|---|---|
| Partial Hospitalization | IN0550 |
| Penile Prosthesis | AH0675 |
| Physical Therapy | ME0675 |
| Physician Services To Family Members | AD0500 |
| Positron Emission Tomography (PET) | RA0200 |
| Post Acute Brain Injury Rehabilitation Facilities | IN0565 |
| Prolonged Physician Attendance | ME0690 |
| Pre-Admission Certification & Length Of Stay | AD0520 |
| Pre-Admission Testing | AD0523 |
| Prescription Drugs | AD0528 |
| Private Duty Nursing | AH0715 |
| Professional Inpatient Benefits | ME0485 |
| Professional Surgical Benefits | SU0650 |
| Psychiatric Home Care | AH0700 |
| Psychological Testing | AH0725 |
| Reconstructive & Cosmetic Surgeries | SU0575 |
| Residential Treatment for Adolescent Psychiatric Care | IN0510 |
| Residential Treatment for Chemical Dependency | IN0520 |
| Routine Infant & Child Health Care | AD0570 |
| Routine Physical & Screening Exam | AD0575 |
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| Medical Policy Name | Number |
|---|---|
| Services Related to Noncovered Services | AD0650 |
| Sex Transformation Surgery | SU0600 |
| Skilled Nursing Facility Benefits | IN0600 |
| Speech Therapy & Electronic Speech Aids | AH0775 |
| Smoking Cessation Services | ME0700 |
| Sterilization | SU0635 |
| Subacute Medical & Rehabilitation Facilities | IN0650 |
| Transplant-Corneal | SU0385 |
| Transplant Coverage Under The SHP | AD0670 |
| Twenty-Three Hour Crisis Stabilization | IN0560 |
| Use Of CPC Medical Policies For The SHP | AD0660 |
