UpDate - Vol. 12, No. 2, Page 8
September 10, 1992
Health Care Benefits
Lab and imaging provider network established
Effective July 1, the state of Delaware initiated significant
cost containment measures for employees, dependents and retirees in
the state health care group. A network of lab and imaging providers
for those enrolled in traditional coverage programs was established
throughout the state. In addition, a new diabetes education benefit
was offered to those enrolled in the state health care group.
Preferred providers for outpatient lab and imaging services, effective
July 1
When your doctor directs you to get outpatient imaging or
laboratory services, remind your doctor that you will receive higher
coverage if you go to a network provider. See the complete list of
preferred provider networks for lab and imaging services below.
Although you are not required to use the Network, doing so can
save you money by lowering the amount of medical costs you'll have to
pay. Using the network provider means you'll receive higher benefit
levels.
How are outpatient lab and imaging services paid?
If your plan covers these services, benefits are paid as follows:
* Imaging Services, such as x-ray, mammography, CAT scan, or MRI,
will be covered 100 percent from a network provider and 65
percent by an out of network provider.
* Lab services, such as blood tests, throat cultures and
urinalysis, will be covered 100 percent by a network provider
and 50 percent by an out of network provider.
Exceptions for outpatient lab and imaging benefits
The following outpatient diagnostic lab and imaging services when
rendered and billed by an out-of-network provider are paid according
to the benefit level described in your benefit booklet. Out-of-network
hospitals noted in the last two bullets of this section refer to
hospitals whose outpatient imaging and/or laboratory departments are
not network providers. You will be receiving updated benefit booklets
which describe more fully how these benefits work.
* Machine Testing such as electrocardiogram,
electroencephalogram, electromyogram (EMG) (Please note,
Machine Testing is not a covered benefit under the Basic Plan.)
* Services rendered and billed by out-of-state providers.
* Services directly related to outpatient emergency care.
Emergency care is treatment required as a result of a sudden,
serious and unexpected condition or illness.
* Services for taking and reading diagnostic x-rays for oral
surgery for bony impacted wisdom teeth.
* Services rendered and billed as part of the hospice program
and home health care benefits.
* Services rendered and billed for in vitro fertilization.
* Diagnostic laboratory and imaging preadmission tests that
are required by an out-of-network hospital to be performed by
them before admitting you. However, services performed by a
provider other than the admitting hospital or the network
provider will be paid at the applicable out-of-network payment
level.
* Diagnostic laboratory and imaging services performed in the
course of a surgical procedure in the outpatient department of
an out-of-network hospital. However, preoperative diagnostic
laboratory and imaging services for surgery performed in the
doctor's office or an ambulatory surgical center must be done
at the network provider or benefits will be paid at the
applicable out-of-network payment level.
Diabetes education
This benefit is covered at 100 percent of the allowable charge
for one course per calendar year if you complete the course. For now,
you can obtain the names and locations of approved providers by
calling Blue Cross Blue Shield of Delaware Customer Service or
Principal Health Care of Delaware at the numbers below.
Blue Cross Blue Shield of Delaware Customer Service Dedicated
Unit: In New Castle County: (302) 428-6080 In Kent and Sussex
Counties: (800) 242-3861
Principal Health Care of Delaware Member Service Dedicated Unit:
In New Castle County: (302) 322-4700 In Kent and Sussex Counties:
(800) 833-7423
After Sept. 1, a list of approved providers will be published.
Starting Oct. 1, you must use only those approved providers.
How can I qualify for the program?
You qualify for diabetes education if:
* You are a newly diagnosed diabetes patient, or are a
previously diagnosed patient with changing needs, and
* You have been referred by your attending physician for
assessment and education.
What is an "approved" program?
The diabetes program must be:
* An approved course. This means it must be conducted by a
diabetic educator certified by the National Board of Testing.
* 8-12 hours in length and held over a period of up to 8
weeks. You are limited to one course per calendar year. You
must complete the course for it to be covered. Courses must
focus on diet, meal planning, blood glucose monitoring, insulin
usage and/or oral medications for diabetes, and foot care. After
completion of the course, you are entitled to two additional
visits per calendar year to clarify methods necessary for you to
manage the disease or to focus on skills required by your
changing needs.
For diabetics diagnosed with gestational diabetes:
* Under traditional plans, the course is covered by the High
Risk Maternity program, which helps to ensure that you will
have a healthy baby.
* In the course of the program your educator may recommend
that you purchase specialized equipment, such as a home glucose
monitoring system. Before you make any purchases of this kind,
you should keep in mind that devices are categorized as durable
medical equipment. As such, they are subject to the durable
medical equipment provisions, outlined in your benefit booklet.
Please review these durable medical equipment coverage
limitations.
* In addition, before purchasing such equipment, you must
obtain proper approval. This means that if you are a member of
The HMO of Delaware, Total Health Plus, or Principal Health
Care of Delaware, you need to receive approval from your
primary care physician. If you have traditional coverage, you
must receive approval through Intracorp.
How is the diabetes education benefit paid?
* You must complete the course first. Then, upon receiving a
bill, you submit it on a customer claim form to your insurance
carrier, either Blue Cross Blue Shield of Delaware or Principal
Health Care of Delaware.