Interqual SmartSheets

Interqual SmartSheet  - Total Joint Replacement, Hip (pdf)

This is a pre-service review form for the Knees, Hips and Back Procedure Review Pilot Program for employees of BCBSNE (YED and NEQ alpha prefixes), EHA (EHN alpha prefix) and MUD (MET alpha prefix) employees and dependents.

Interqual SmartSheet - Total Joint Replacement, Knee (pdf)

This is a pre-service review form for the Knees, Hips and Back Procedure Review Pilot Program for employees of BCBSNE (YED and NEQ alpha prefixes), EHA (EHN alpha prefix) and MUD (MET alpha prefix) employees and dependents.

Interqual SmartSheet - Angioplasty and Stent Carotid (pdf)

This is a pre-service review form for all BCBSNE members for the prior authorization program.

Interqual SmartSheet - Endometrial (pdf)

This is a pre-service review form for all BCBSNE members.

Interqual SmartSheets - Hysterectomy 

These are the SmartSheets for the hysterectomy pre-service review program for all BCBSNE members.

Interqual SmartSheets - Kyphoplasty (pdf)

Pre-service review form for all BCBSNE members for the prior authorization program.

Interqual SmartSheets - Left Ventricular Assist Device (LVAD) Insertion (pdf)

Pre-service review form for all BCBSNE members for the prior authorization program.

Interqual SmartSheets - Mastectomy (pdf)

Pre-service review form for all BCBSNE members for the prior authorization program.

Interqual SmartSheets - Obesity Surgery 

Click here to access the SmartSheets for the obesity surgery pre-service review program for all BCBSNE members.

Interqual SmartSheets - Pacemaker Insertion (pdf)

Pre-service review form for all BCBSNE members for the prior authorization program.

Interqual SmartSheets - Radiofrequency Ablation (pdf)

Access the pre-service review forms for all BCBSNE members for the prior authorization program.

Interqual SmartSheets - Reduction Mammoplasty 

Access the pre-service review forms for all BCBSNE members for the prior authorization program.

Interqual SmartSheets - Sinus Surgery 

Click here to access the SmartSheets for the sinus surgery pre-service review program for all BCBSNE members.

Interqual SmartSheets - Sleep Studies 

Click rel="noopener noreferrer" here to access the SmartSheets for the sleep studies pre-service review program for all BCBSNE members.

Interqual SmartSheets - Stimulation Surgery 

Click here to access the SmartSheets for the stimulation surgery pre-service review program for all BCBSNE members.

Interqual SmartSheets - Varicose Veins 

Click here to access the SmartSheets for the stimulation surgery pre-service review program for all BCBSNE members.

Interqual SmartSheets - Vertebroplasty (pdf)

Pre-service review form for all BCBSNE members for the prior authorization program.

* Electronic forms require Internet Explorer web browser and Adobe Acrobat PDF software. Mac users may download the form to their desktop and complete using Adobe Acrobat.

HEALTH INSURANCE TERMS


COINSURANCE

The percentage of the bill you pay after your deductible has been met.

COPAY

A fixed amount you pay when you get a covered health service.

Tiered benefit plan

A health care plan featuring multiple levels of benefits based on the network status of a particular provider. 

DEDUCTIBLE

The annual amount you pay for covered health services before your insurance begins to pay.

emergency care services

Any covered services received in a hospital emergency room setting.

SUBSTANCE ABUSE DISORDER SERVICES

Includes behavioral health treatment, counseling, and psychotherapy


in-network provider

A provider contracted by your insurance company to accept an agreed upon payment for covered services. 

OUT-OF-network provider

A term for providers that aren’t contracting with your insurance company. (Your out-of-pocket costs will tend to be more expensive if you go to an out-of-network provider.)

out-of-pocket

Your expenses for medical care that aren’t reimbursed by insurance, including deductibles, coinsurance and co-payments.

penalty

If you can afford health insurance, but choose not to buy it, you must have a health coverage exemption or pay a tax penalty on your federal income tax return.

premium

The amount you pay to your health insurance company each month. 


Preventive services

Health care services that focus on the prevention of disease and health maintenance.

rehab SERVICES

Services and devices to help you recover if you are injured or have surgery. This includes physical, occupational and speech therapy.

special enrollment period

The time after the Open Enrollment Period when you can still purchase health insurance only if you have a qualifying life event (losing other health coverage, having a baby, getting married, moving).

specialist

A physician who has a majority of his or her practice in fields other than internal or general medicine, obstetrics/gynecology, pediatrics or family practice.