Provider Manual

Summary of Covered and Non-Covered Services

There are defined sets of healthcare services that members may access that are considered “covered services” and which are payable by the 1199SEIU Benefit Funds. Covered services are medically necessary services set forth in the SPDs administered by the Benefit Funds. It is within the sole discretion of each Benefit Fund’s Plan Administrator to determine whether a particular service is a covered service and cannot be challenged by a provider. Some services may require prior approval.

Covered Services

A comprehensive list of covered services can be found in the member’s SPD.

In general, comprehensive primary care; specialty care; outpatient laboratory and radiology; emergency care; hospitalization; and ambulatory care procedures are covered by the 1199SEIU Benefit Funds. Coverage may vary depending on the member’s Benefit Fund, which can be found on their Health Benefits ID card. If you have questions regarding coverage, you may verify via NaviNet or our automated Interactive Voice Response (IVR) system 24 hours a day, 7 days a week, by calling (888) 819-1199.

Medical services co-payments

Even though a service is covered, co-payments may apply. These co-payments will be listed on the member’s Health Benefits ID card.

There is no co-payment for preventive services such as annual checkups and well-child visits. You can find a full list of preventive services on www.Healthcare.gov.

If you are not sure which Benefit Fund covers your 1199SEIU patients, you can check the front of their Health Benefits ID cards, log into NaviNet or call the Benefit Funds’ automated eligibility IVR system at (888) 819-1199.

Dental services

Benefit Funds members have access to comprehensive dental coverage administered by the Benefit Funds’ dental coverage partners. Members’ dental coverage varies by Benefit Fund; details are on our website.

Prescription drug services

Members are covered for drugs prescribed in accordance with the 1199SEIU Benefit Funds’ Preferred Drug List. As a reminder, by New York State law, all prescriptions must be submitted electronically. The Benefit Funds have a custom participating pharmacy network. Please refer members to any participating pharmacy for acute treatment and the first fill of a maintenance medication.

For maintenance medications: For maintenance medications, the Benefits Funds use The 90-Day Rx Solution. Members must order maintenance medications in three-month supplies through the Benefit Funds pharmacy benefit manager (PBM) by mail or at a participating pharmacy. (Learn more.)

For specialty medications: If a member requires specialty medications—those that usually require injection or special administration—they will:

  • Order a 30-day supply through the specialty pharmacy mail order service.
  • Receive their medications through a reliable delivery service, like UPS, free of charge.

For more information, visit our Prescription Program page.

Prior authorization for prescriptions: Procedures for requesting prior authorization for prescription drugs vary. Please check our Prescription Program page for current programs and prior authorization details.

Non-Covered Services

Services and charges not included in a member’s SPD are considered “non-covered” and are not payable by the 1199SEIU Benefit Funds. Before these services are provided, providers are required to notify the member in writing that the services are not covered. Such notification must specify the services that are non-covered services; list the costs of those services to the member (the member will be personally responsible for the costs of these services); and document the member’s consent in writing to have the service(s) performed.

The following list provides some examples of commonly denied non-covered services. This is not an exhaustive list. For a full list of non-covered services, please refer to the appropriate SPD.

The Benefit Funds do not cover:

  • Services that, in the judgment of the Plan Administrator, are not medically necessary
  • Services that are not pre-approved in accordance with the SPD
  • Experimental and/or unproven services, treatments, supplies, devices, tests or drugs
  • Services related to an illness or injury where payment for the services is the legal responsibility of another person, firm, corporation, insurance company, payer, uninsured motorist fund, no-fault insurance carrier, workers’ compensation carrier or other entity
  • Newborn hospital stays for newborns who are not enrolled or eligible to enroll
  • Operating room charges, or facility fees, to office-based surgery suites regulated under Section 230-d of the New York Public Health Law
  • Inpatient sub-acute care in a hospital
  • Custodial care in a hospital, skilled nursing facility, nursing home, residential treatment facility or any other institution
  • Venipuncture
  • Refraction services provided by an MD or ophthalmologist
  • Services provided to members during periods when they were not eligible