Back to Chapter 4 Table of Contents Covered
Not Covered
Benefits
CC & IFP
Skilled Nursing Facility (SNF)
Details and Limitations
EG
Covered CA and IFP members: Coverage is limited to 100 days per calendar year of prescribed and authorized skilled nursing services in a VHP contracted SNF or a skilled nursing bed in a VHP contracted hospital. Employer Group members (Classic and Preferred): Coverage is limited to a maximum of 100 days per calendar year.
Specialist Visit
A referral from the member’s PCP is required. Failure to receive prior authorization approval by VHP will result in the denial of the unapproved specialty visit and all services rendered in conjunction with that visit.
Substance Abuse Disorder Inpatient Services
Refer to Chapter 19, “Behavioral Health Services.”
Substance Abuse Disorder Outpatient Services
Refer to Chapter 19, “Behavioral Health Services.”
Transplant
Limitations & Exclusions include: Services for organ, tissue and bone marrow transplant treatment are subject to the limitations and exclusions as outlined under the member’s EOC. Services must meet the medically necessary criteria and be approved by VHP. Organ donor searches and recipient or donor transportation costs to the transplantation center are excluded from coverage under the benefit plan.
Transportation
Emergency medical transportation: Covered. Non-emergent medical transportation: Covered only for medically necessary inter-facility transportation.
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2021 / Provider Manual
CH 4: Member Benefits, Exclusions, & Limitations
