A wide array of inpatient and outpatient benefits are provided through CMSP. Covered services are subject to treatment authorization requirements and utilization limits and generally include the following:
- Acute inpatient hospital care
- Adult Day Health Care
- Blood and blood derivatives
- Chronic hemodialysis services
- Dental services
- Durable medical equipment
- Emergency ambulance services and medically necessary transportation from the acute hospital to other facilities for medically necessary, specialized, or tertiary care
- Hearing aids
- Home Health Agency services
- Hospital outpatient and outpatient clinic services
- Laboratory and radiology services
- Medical supplies dispensed by physicians, licensed pharmacies, or durable medical equipment dealers and prosthetic or orthotic providers
- Non-emergency medical transportation
- Optometry services including an eye examination and an allowance up to $80 for materials (lenses & frames), including low vision aids, once every 24 months
- Outpatient audiology services
- Outpatient heroin detoxification services (does not include methadone maintenance)
- Outpatient occupational therapy services
- Outpatient physical therapy services
- Outpatient rehabilitation services in a rehabilitation facility
- Outpatient speech pathology services
- Prescription Drugs
- Physician services
- Podiatry services
- Prosthetic and orthotic appliances
- Psychiatric services provided by a licensed psychiatrist
Specific services that are not covered by the program include acupuncture, chiropractic services, pregnancy-related services, long-term care or skilled nursing facility services, psychological services provided by non-psychiatrist providers, replacement eye glasses and repairs, contact lenses that are not medically necessary; methadone maintenance, and all services not covered by the Medi-Cal program.
Treatment Authorization
Effective October 1, 2005, CMSP is administered by Anthem Blue Cross
Life and Health Insurance Company. Please note the following requirements
for treatment authorization:
Claims for CMSP services are subject to treatment authorization requirements
and utilization limits administered by Anthem Blue Cross on behalf of
CMSP. In general, all medical service authorizations are to be sent
to Anthem Blue Cross. Dentists and Optometrists that are not part of
an FQHC, RHC or tribal health clinic are required to submit authorizations
to Doral Dental and Vision Service Plan (VSP), respectively. The CMSP/Anthem
Blue Cross Provider Operations Manual (POM) is provided to all providers
that contract to be a part of the CMSP/Anthem Blue Cross provider network.
The POM describes how to obtain service authorizations and how to bill
for services.
Prior authorization for CMSP prescription drug services that are delivered through a retail pharmacy are handled by MedImpact Healthcare Systems, Inc. (MedImpact).