Limitations & Exclusions

Prior Authorization Process
Prior Authorization is the process of PPK determining whether the Health Care Service is a Covered Service, Medically Necessary, and being rendered by Contracting Providers. Coverage is subject to eligibility and benefits remaining at the time services are rendered.

Referral Process
PPK members are responsible for obtaining a referral authorization from their PCP for all Health Care Services (except Emergency Services, annual well-woman exam, annual diabetic retinal eye exam, and prospective parent PCP visit) rendered outside his/her office. Behavioral health, substance abuse, and Biologically Based Mental Illness services do not require a PCP referral authorization, however, they must be Prior Authorized by PPK.

Pre-Existing Condition
A pre-existing condition provision may apply if medical services are received during the first 90 days after the effective date of coverage and medical advice, care or treatment, or diagnosis was made or received for the same condition 90 days prior to the effective date of coverage. The provision will not apply if you and/or your dependent(s) have been covered under another health insurance policy within 63 days prior to the effective date of this coverage, without a gap in such coverage. The pre-existing condition exclusion does not apply to pregnancy nor to a child who is enrolled in the plan within 30 days after birth, adoption, or placement for adoption.

Exclusions

1. Services not provided, ordered, or referred by your PCP (except for Emergency Services, well-woman exam, annual diabetic retinal eye exam and the prospective parent PCP visit).

2. Services of Non-Contracting Providers except for Emergency Services or when authorized by the Member’s PCP and prior authorized by PPK.

3. Any services which are not Medically Necessary.

4. Experimental, Investigational, unproven or obsolete treatments, procedures or devices and related services, unless otherwise described in this Certificate.

5. Transplants, except as described in this Certificate.

6. Cosmetic treatment or surgical procedures primarily to restore or alter appearance unless specified in the Reconstructive Treatment/Surgery benefit section of this Certificate.

7. Vitamins, minerals, nutritional supplements, or special diet foods whether or not required by a Physician.

8. Costs associated with commercial pain management programs.

9. Cosmetic, health, and beauty aids.

10. Chelation therapy, except for acute arsenic, gold, mercury or lead poisoning.

11. Evaluations and diagnostic tests ordered or requested in connection with criminal actions, divorce, child custody, or child visitation proceedings and any assessment against any person required by a diversion agreement or by order of a court to attend an alcohol and drug safety action program certified pursuant to K.S.A. 8-1008 and amendments thereto.

12. Treatment of teeth or structures directly supporting the teeth including, but not limited to: extraction of teeth (including bony impacted wisdom teeth), routine cleaning, dental examination, x-rays, and repairs, fillings, scaling, scraping and/or root planing, dentures, bridges, dental implants, casts, splints, straightening of teeth, services for dental malocclusion, maxillofacial orthognathic and prognathic treatment/surgery, orthodontics, periodontics, or hospitalizations for non-covered services, except as specified in the Oral Surgery and Other Related Services and the Transplant sections of this Certificate.

13. Services or supplies related to intersex surgeries.

14. Non-medical ancillary services including, but not limited to: legal services, social rehabilitation, vocational rehabilitation, work reintegration training, work hardening or conditioning, behavioral training, sleep therapy, employment counseling; educational testing, training, or therapy, unless approved by PPK as part of treatment for traumatic head injury or stroke, or as specified in the Diabetic Services and Maternity Care sections.

15. Items of wearing apparel, except as described under the Compression Stockings, Prosthetic Devices, Orthotic Devices or Reconstructive Treatment/Surgery sections of this Certificate.

16. All charges for or related to autopsies, except when requested by PPK.

17. All charges related to complementary/alternative medicine including, but not limited to: sensory integrative techniques, music therapy, guided imagery, therapeutic touch, aroma therapy, acupressure, hydro-massage, Vax-D therapy, reflexology, craniosacral therapy, acupuncture and therapy for the development of cognitive skills to improve attention, memory or problem solving, including compensatory training.

18. All prescription drugs, non-prescription drugs, and Investigational and Experimental drugs, except as described as covered in this Certificate.

19. Routine foot care including the paring and removing of corns and calluses or trimming of nails unless Medically Necessary for the treatment of a person who, due to a demonstrated medical condition, is unable to perform such activity.

20. Cost of biologicals that are immunizations or medications to protect against occupational hazards and risks.

21. Care for health conditions required by state or local law to be treated in a public facility.

22. Services for injuries or diseases related to your employment to the extent you are covered or are required to be covered by the workers’ compensation law. If the Member enters into a settlement giving up rights to recover past or future medical benefits under workers’ compensation law, PPK will not pay past or future medical benefits that are the subject of or related to that settlement. In addition, if the Member is covered by a workers’ compensation program, which limits benefits other than specified by the program, PPK will not pay balances of charges from such non-specified Providers.

23. Benefits of this Certificate will not duplicate benefits provided under Federal, State or local laws, regulations or programs.

Examples of such programs are: Medicare, CHAMPUS, Tricare and services in any veteran’s facility when the services are eligible for coverage by the government. This Certificate will provide coverage on a primary or secondary basis as required by state or federal law. This exclusion does not apply to Medicaid. This exclusion applies whether or not you choose to waive your rights to these services.

24. Services resulting from war or an act of war.

25. Whole blood, and blood plasma or payments to donors for blood or payment to a blood collection site.

26. Transportation, food, and lodging unless otherwise described in this Certificate.

27. The costs of health services resulting from accidental bodily injuries arising out of the ownership, operation, maintenance, or use of a motor vehicle to the extent such services are required to be covered by motor vehicle financial responsibility laws, regulations, or programs, or are payable under any medical expense payment provisions (by whatever terminology used-including such benefits mandated by law) of any automobile insurance policy.

28. Services performed by the Member or their parent, spouse, sibling, or child.

29. Injuries incurred while the Member is in the commission or attempted commission of a felony.

30. Services or items for the convenience of the Member or Provider including, but not limited to, home laboratory testing and duplication of covered durable medical equipment.

31. Services when the Member is not present including, but not limited to, case management team conferences, telephone calls, electronic communication, telemedicine, and consultations with family members.

32. Any service(s) rendered where the Member(s) receives monetary or in-kind enticement, incentive, rebate or kickback of any kind from a Provider(s) or agent(s) of a Provider(s).

33. Any service(s) rendered and/or billed by a Provider through misrepresentation of material fact or fraud.

34. Items not strictly for the purposes of treating a medical condition including, but not limited to: over the counter batteries, massagers, air/water purifiers, air conditioners, pillows, mattresses, communication devices/aids, whirlpools, bedwetting alarms, prenatal cradles, breast pumps, car seats, strollers, shower chairs, commodes, thermal therapy devices, or modifications to the Member’s home or vehicle.

35. Any portion of a Claim that PPK determines to be incorrectly or inappropriately billed by a Physician, Health Professional, Facility or Hospital. This includes, but is not limited to: unbundling of procedural services, office visits that take place within a global period, and inappropriate modifier use.

36. Services related to the treatment of temporomandibular joint disease (TMJ) and Myofascial Pain Dysfunction Syndrome (MPDS).

37. Costs associated with smoking cessation programs.

38. Medical and hospital care and costs for the infant child of a Dependent.

39. Elective abortions.

The Certificate of Coverage you will receive when you enroll will contain complete benefit descriptions, exclusions and limitations.

PPK 255 G 1/04
PHS-207/-2/04