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Children’s Contracts with Managed Care Plans

Children’s is contracted with several managed care plans. Generally these contracts provide for Children’s participation for the full scope of services offered by the Hospital and Children’s physicians. In some cases, however, managed care plans have implemented separate networks of providers to deliver particular types of services, such as behavioral. Under this type of arrangement, referred to as a “carve-out,” not all providers who are affiliated with Children’s are participating providers in the carve-out network. The following identifies by department the carve-out arrangements used by specific managed care plans.

Information is provided on whether Children’s is currently a participating provider in the particular arrangement. Please note that such carve-out arrangements are often limited to particular products offered by the managed care organization, such as the HMO. Referring physicians and plan enrollees are encouraged to discuss the scope of the carve-out with the plans’ provider and member services representatives if there are questions about whether a carve-out applies to a particular member. In cases where Children’s is not participating in a particular carve-out network, it may be possible to obtain special authorization for services if a member’s needs cannot be accommodated within that network. While every effort has been made to present comprehensive information on the specialized arrangements, these types of arrangements are subject to change.

Departmental Carve-out Arrangements for Specific Managed Care Plans
Plans for which Children’s is not a designated participating provider may authorize services at Children’s on an exception basis when specialized pediatric expertise is not available within their network of contracted providers.

In addition, members enrolled in PPO or Point of Service products generally have the option to access benefits through non-participating providers with greater out-of-pocket expense.

The following identifies by department the carve-out arrangements used by specific managed care plans. The third column, entitled Children’s Status, identifies whether Children’s is currently a participating provider under carve-out arrangements.

PLAN

CARVE-OUT

CHILDREN’S STATUS

Laboratory Medicine

Note: Many HMOs have carve-out arrangements for outpatient laboratory services. The hospital and all Children’s Outpatient Centers except Frederick are drawing stations and stat sites for Lab Corp. The Hospital is a drawing site for Quest.

Ophthalmology

Cigna

Advantica EyeCare (Allied)

Participating

Note: The carve-out arrangements noted above are for medical services. Many managed care plans have designated providers for routine eye care, such as vision testing and refractions. These are not noted as Children’s does not provide routine eye care. Refer to plan directories for information on routine vision services.

Physical Medicine and Rehabilitation Medicine

Physical Therapy and Occupational Therapy are coordinated through this department. The following carve-outs apply for these therapy services.

*CareFirst

*Note: Children’s does not have a separate professional services agreement with CareFirst for therapy services. Therapy services provided at Children’s for individuals covered by the Federal Employee Plan are processed under provisions for hospital benefits. Children’s is not considered a participating provider for Blue Choice.

Psychiatry and Psychology*

*Due to the complexity of mental health benefit carve-outs and variations by employer group, benefit information should be verified directly with the health plan.

Aetna

Outpatient Professional

Non-Participating

Amerigroup DC

Contact Amerigroup

Non-Participating

Amerigroup Maryland

Maryland American Psych

Systems (MAPS)

Participating

CareFirst HMO

Magellan

Non-Participating

Chartered Health Plan

Contact Chartered

Non-Participating

Cigna

Cigna Behavioral Health

Non-Participating

Kaiser

Children’s is contracted with Kaiser for day treatment and inpatient services.

Participating

Tricare (CHAMPUS)

Non-Participating

United HealthCare**

United Behavioral Health

Non-Participating

**(Children’s is a participating provider for members covered through Maryland Medicaid.)

Diagnostic Imaging and Radiology

Kaiser

Medical Imaging Network

Participating*

*Children’s Hospital and the Northern Virginia, Laurel and Upper Marlboro Outpatient Centers are participating MIN locations.

For billing and insurance questions call 301-572-3542 or 1-800-787-0021.

 


 
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