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.
New Jersey Department of Banking and Insurance. New Jersey Administrative Code. Title 11: Insurance. Chapter 24: Health Maintenance Organizations. Subchapter 9: Member rights and responsibilities: Disclosures to consumers. §11:24-9.1: Policies and procedures. [The State of New Jersey Web site]. Original: 12/31/02. (Recodified: 10/06/06). Available at: http://www.state.nj.us/dobi/division_insurance/managedcare/omc/njac11c24.pdf. Accessed March 20, 2008.
Stanos SP, Tyburski MD, Harden RN. Management of chronic pain: Multidisciplinary and interdisciplinary approaches. In: Braddom RL, Buschbacher RM, Chan L, et al.,eds. Physical Medicine and Rehabilitation. 3rd ed. Philadelphia, PA: WB Saunders Co.; 2007:966-968.
Policy: 07.13.01h:Orthoptic/Pleoptic Training
Policy: 10.02.02j:Chiropractic Spinal and Extraspinal Manipulation Therapy
Policy: 10.03.01l:Physical Medicine, Rehabilitation, and Habilitation Services
Policy: 10.06.01l:Speech Therapy