Medical Policies


Employer Provider Network, Inc.

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Members of some group health plans may have terms of coverage or benefits that differ from the information presented here. The following information describes the general policies of CCStpa and is provided for reference only. Pre-admission or prior authorization/ pre-certification notification is not a guarantee of payment. Benefits quoted are a general outline of coverage and are subject to all provisions and limitations in the subscriber’s contract. Inpatient hospitalization must be medically necessary and be the appropriate level of care for the procedure or condition being treated. You may be required to provide additional clinical information. To verify coverage or benefits or determine pre-certification or pre-authorization requirements for a particular member, call 1-800-365-2735 or 651-662-5940 or send an electronic inquiry through Availity.com.

Benefit plans vary in coverage and some plans may not provide coverage for certain services discussed in the medical policies. Some self – insured plans, may have additional policies and prior authorization requirements. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law.

Receipt of benefits is subject to all terms and conditions of the member's plan documents. Members and providers should consult their contract, certificate of coverage, or summary plan description (SPD), as applicable, to review the provisions relating to a specific coverage determination, including exclusions and limitations. If there is a conflict between the information above and the contract or plan documents, the contract or plan documents govern.

These medical policies in no way imply that members should not receive specific services based on the recommendation of the provider. These policies govern coverage and not clinical practices. Providers are responsible for medical advice and treatment of patients. Members with specific health care needs should consult an appropriate health care professional.

Members and providers have rights to appeal coverage decisions. These rights are spelled out in member or provider plan documents. If members have questions about appeal rights, they should contact customer service at the number located on the back of the member ID card. If providers have questions about appeal rights, contact provider services at (651) 662-5940 or toll free at 1-800- 365-2735.

This information is not an offer of coverage, solicitation of coverage, summary of coverage or guarantee of coverage. All products and coverage guidelines are subject to applicable laws and regulations. Member or provider coverage is contingent on all the applicable terms, conditions, limitations and exclusions of member or provider plan documents.

Medical Policy and Utilization Management

Providers: If you have questions, please call 1-800-365-2735 or 651-662-5940.

Members: If you have questions, please call the number on the back of your member ID card or 1-866-356-2425 or 651-662-5425.


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Acknowledgements
The five-digit numeric codes that appear on the medical policies on this web site were obtained from the Physician's Current Procedural Terminology, as contained in CPT-2016, © 2015 American Medical Association.
Current Dental Terminology © 2016 American Dental Association. All rights reserved.
Prime Therapeutics LLC is an independent company providing pharmacy benefit management services