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Occupational Therapy Occupational therapy services are covered when prescribed by the participant’s physician and specified in a treatment plan. Blue Cross & Blue Shield may require proof of medical necessity. Services must be provided by a licensed occupational therapist.

Physical Therapy Physical therapy services are covered when prescribed by the participant’s physician and specified in a treatment plan. Blue Cross & Blue Shield may require proof of medical necessity. Services must be provided by a licensed physical therapist.

Physician Services The following physician services are covered:

  • In-hospital medical care

  • Medical care in the physician’s office, patient’s home, or elsewhere

  • Surgery and assistance at surgery (when appropriate and provided by a physician practicing within the scope of his license)

  • Consultations

  • Administration of anesthesia

  • Radiation therapy

  • Obstetrical care

  • X-rays and laboratory tests performed in a physician’s office, except when performed during routine examinations, unless applied to the wellness benefit

  • Psychiatric and psychological services for mental health treatment

  • Allergy testing

  • Covered dental care

  • Dialysis treatment

Benefits for physician services are allowed based upon the coding guidelines used by Blue Cross & Blue Shield.

Multiple Surgery Special rules apply to multiple surgery procedures performed by the same physician during the same operation. If more than one surgical procedure is performed during the same operation through one or more routes of access, the allowable charge will be calculated as follows:

The amount payable

50% of the allowable charge that

for the primary procedure

+

would have been allowed for each of the additional procedures had those procedures been performed alone.

Any of the costs associated with additional procedures (incidental procedures) not essential to the purpose of the primary procedure are not covered.

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