Rates effective June 1, 2012

Attachment A lists rates effective June 1, 2012 (with the exception of Service Coordination and Enrollment**).

Attachment A — fee table rows and flags

Fee schedule rows show procedure codes with dollar amounts, billing time units, and applicability markers ('x' and 'N/A') indicating service-specific applicability; example codes visible include W1011, W0104, T2025, W0100.

Fee schedule — no authorization rules in this section

Attachment A is a fee schedule that lists procedure codes and payment amounts; this section contains no prior authorization, step therapy, denial-risk, or explicit documentation requirements in the provided excerpts.

Bill using listed codes, units, and regional rates

The fee schedule provides unit rates and region applicability for each listed code; providers must bill using the procedure codes and corresponding units shown in the schedule when submitting claims.

• Match the submitted procedure code to the Attachment A code row.
• Use the billing unit shown (e.g., 15 Minutes, 1 Hour, 1 Day, 24 Hours, 1 Month, One Time).
• Apply the regional rate column that corresponds to the member's region.

Rate schedule — no authorization guidance in this segment

This attachment maps procedure codes to reimbursable amounts and time units; the excerpt does not specify any prior authorization or other authorization actions.

Fee schedule attachment — no prior authorization text

Attachment A lists procedure codes with regional rates and billing units; no prior authorization rules are included in the shown excerpt.

Fee schedule — no authorization instructions present

Attachment A lists procedure codes and corresponding regional rates; the provided fragments do not include any prior authorization instructions.

Fee schedule excerpt — no auth rules

The fee schedule excerpt lists procedure codes and rates by region and unit; no prior authorization rules are shown in this segment.

Refer to Attachment A for codes, units, and regional rates when billing

Providers should reference Attachment A for procedure codes (examples: S5102, W0009, W7341, T2025) and the regional payment rates and unit definitions when preparing claims.

• Verify the correct code and any modifier (e.g., U4, U5) before billing.
• Select the unit type listed (e.g., 1 Day, 1/2 Day, 15 Minutes, 1 Month, One Time).
• Apply the Region 1–4 rate column appropriate for the member.

Fee schedule — no authorization rules included

Fee schedule rows include procedure codes and regional/unit payment amounts; no prior authorization rules appear in this fragment of Attachment A.

Reimbursement fee schedule — sample codes and units

Fee schedule entries list sample procedure codes (e.g., S5102, W0009, W7341, T2025, 97537) with associated billing units and region-specific rates.

• Example entries: S5102 (1 Day / 1/2 Day variants), W0009 (One Time $95.00), W7341/W7341 U4 (1 Month $77.00 / 1 Time $277.00).

Use rate and unit columns shown on fee schedule

Fee schedule rows display procedure codes, rate values by region, and unit definitions (examples include 15 Minutes, 1 Hour, 1 Day, 1 Month, One Time) that providers must use when billing.

Fee schedule — no denial or prior auth process described here

The fee schedule lists codes and rates but does not specify prior authorization or claim denial processes in the shown excerpts.

Match code, modifier/unit, and region to set reimbursement

Attachment A is a fee schedule of procedure codes with region-specific rates and billing units; providers should match code, modifier/unit, and region to determine the reimbursable amount.

• Confirm modifier and unit (e.g., U4 = 1 Time, U5 = 1/2 Day) as listed.
• Use the rate shown under the member's region column.

Fee schedule — no authorization or denial guidance present

Attachment A provides only the fee schedule; the excerpt does not include prior authorization, documentation, step therapy, or explicit denial-risk instructions.