Supplemental Benefits
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Defines Longevity Health Plan of Colorado's coverage criteria and prior authorization requirements for supplemental benefits (e.g., dental, hearing aids) offered to plan beneficiaries; applies to providers and members under the Plan.
No material clinical or coverage changes in this revision.
Supplemental Benefits Coverage Criteria
Supplemental Benefits Coverage Criteria
Covered when ALL of the following are met
Supplemental benefits vary by plan; information available at www.longevityhealthplan.com. Providers should confirm available benefits before rendering services.
Prior authorization requirements for supplemental benefits are listed at www.longevityhealthplan.com.
Medical necessity criteria will be applied when prior authorization is required; benefit exhaustion or cost limitations are not considered in the prior authorization medical necessity determination.
Plan limitations and whether a member has exhausted benefits or reached cost limits are considered administrative determinations and are not evaluated as part of the prior authorization medical necessity determination. When completing a prior authorization review for supplemental benefits, reviewers will apply clinical medical necessity criteria without factoring benefit exhaustion or cost limitations into that medical necessity decision.
When a supplemental benefit requires prior authorization per the member's plan design, the request will be reviewed using medical necessity criteria. Providers must confirm whether prior authorization is required and obtain it before rendering services when applicable; medical necessity is applied specifically in those cases to determine coverage eligibility for the requested supplemental service.
Provider Responsibilities and Prior Authorization
Prior authorization may be required — follow PA process
Prior authorization may be required for supplemental benefits; when required, medical necessity criteria will be applied and providers must confirm benefits before rendering services and follow the plan's PA process.
- Prior authorization requirements for supplemental benefits can be found at www.longevityhealthplan.com.
- Providers should confirm available benefits before rendering services.
Provider action: verify benefits and PA requirements
Confirm member-specific supplemental benefit eligibility and whether the benefit requires prior authorization before scheduling or delivering services.
- Verify benefit inclusion in the member's plan design.
- Check www.longevityhealthplan.com for plan-specific PA requirements.
Include clinical evaluation and assessment with PA request
When prior authorization is required, the rendering provider must submit clinical information confirming the member was evaluated by an appropriate qualified healthcare provider and include assessment/exam findings that justify the requested supplemental services.
- Include documentation of the evaluation, assessment findings, and exam results that support medical necessity.
Risk of denial if PA not obtained
Services may be denied if prior authorization was required but not obtained; providers must confirm benefits and obtain PA when indicated to avoid denial of services.
- Services rendered without confirming available benefits may be denied if prior authorization was required but not obtained.
Policy Background
Supplemental benefits are additional services offered under specific plan designs and may include items such as dental care and hearing aids. These benefits vary by plan and may be subject to plan-specific limitations, so providers and members should confirm benefit availability and any prior authorization requirements on the plan's website before services are rendered.
Key Definitions
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