Covered and Noncovered Services

Covered Services

HIRSP will cover medically necessary and appropriate services consistent with the HIRSP policy. Prescription drugs must be obtained at a HIRSPcertified network pharmacy. A partial list of covered services follows.
Refer to the policy for a full list of covered services, exclusions, conditions, and limitations.

Covered Services

• Medical-surgical services
• Anesthesia services
  
• Consultations
  
• Prescription drugs
  
• Home care
  
• Radiology services
  
• Laboratory services
  
• Pap test and pelvic exam
  
• Prostate cancer screening
  
• Skilled nursing care
  
• Hospice care
  
• Services and supplies for treatment of diabetes
  
• Yearly routine exam (*see italicized text below).

Prior Approval of Health Care Services

Note: Prior approval does not apply to the HIRSP Medicare Supplement plan.

The Plan Administrator’s prior approval is required in order to receive benefits for charges for covered expenses for certain health care services covered under this policy.  Health care services requiring the Plan Administrator’s prior approval are listed below.  You are responsible for assuring that the required prior approval is received before health care services are provided by calling 1-866-841-6572 or faxing the request for prior approval to 1-608-226-4777.  Failure to comply with the prior approval requirements, excluding paragraph 8. below, will result in no coverage for such health care services.

To assure that health care services are covered, you must obtain the Plan Administrator’s prior approval before you receive any of the following health care services: 

1. Surgical services for morbid obesity;
2. Reduction mammoplasty, septoplasty, and blepharoplasty;
3. Transplant services;
4. Any durable medical equipment that will be rented for more than three months or with a purchase price greater than $1,500;
5. Any prosthetic with a purchase price greater than $1,500;
6. Pain management procedures as follows:  (a) percutaneous intervertebral disc procedures (intradiscal electrothermal therapy (IDET), intradiscal electrothermal annuloplasty (IDEA), percutaneous intradiscal radiofrequency thermocoagulation (PIRFT), nucleoplasty, laser assisted disc decompression (LADD), percutaneous disc decompression, chemonucleolysis; (b) radiofrequency neuroablation (neurolysis) of the facet joint nerves; (c) facet joint injections and medial branch nerve blocks; (d) trigger point injections; (e) epidural injections, other than epidural injections provided to the pregnant participant in connection with labor or delivery of a newborn child or due to surgery;  (f) sacroiliac joint injections; and (g) artificial intervertebral disc replacement (lumbar artificial disc replacement (LADR) and intervertebral disc prosthesis).
7. The following additional health care services, except when such services are provided in an emergency:
   1. Spinal surgeries;
   2. PET scans;
   3. MRA studies;
   4. Dental repair related to an injury;
8. Inpatient admissions.  Approval must be received for non-emergency admissions, at least three business days prior to the confinement.  Please see Section X. for the procedures to obtain hospital admission authorization in order to avoid a penalty;
9. Outpatient visits and transitional treatment arrangements for treatment of alcoholism, drug abuse and nervous or mental disorders beyond 50 visits per calendar year;
10. Spinal cord stimulators;
11. Implantable infusion pain pump;

For more specific information about covered services, refer to the HIRSP policy or contact HIRSP Customer Service.