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Medicare Advantage Prior Authorization

Requirements

This list contains prior authorization requirements for Medicare Advantage for inpatient and

outpatient services.

Procedure/Service

Comments

Inpatient Hospital—Acute Residential Behavioral Health Skilled Nursing Facility Outpatient Rehabilitation—

(PT/OT/ST, TMS, Electroconvulsive Therapy)

Procedure/HCPCS Codes: 92507, 92508, 92521, 92522, 92523, 92524, 92597, 92607, 92608, 92609, 95992, 96105, 96110, 96112, 96113, 96125, 97012, 97014, 97016, 97018, 97022, 97024, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97129, 97130, 97139, 97140, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97530, 97533, 97535, 97537, 97542, 97750, 97755, 97760, 97761, 97763, 97799, G0283, 90867, 90868, 90869, 90870 PT/OT/ST—No auth required for first 12 visits

Partial Hospitalization Revenue Codes: 0912, 0913 Home Health Procedure/HCPCS Codes: G0179, G0180 Revenue Codes: 0261, 0421, 0431, 0441, 0551, 0561, 0571, 0581

No auth required for first 12 visits

Attended Sleep Studies

Procedure/HCPCS Codes:

95782, 95783, 95805, 95807, 95808, 95810, 95811

Podiatry Services

Procedure/HCPCS Codes:

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Procedure/Service

Comments

Genetic Testing Procedure/HCPCS Codes: 81120, 81121, 81162, 81163, 81164, 81165, 81166, 81167, 81170, 81175, 81176, 81200, 81201, 81202, 81203, 81206, 81207, 81208, 81210, 81212, 81215, 81216, 81217, 81218, 81219, 81220, 81221, 81222, 81223, 81225, 81226, 81227, 81233, 81235, 81236, 81237, 81240, 81241, 81242, 81245, 81246, 81250, 81251, 81252, 81253, 81254, 81255, 81256, 81257, 81258, 81259, 81261, 81262, 81263, 81265, 81266, 81267, 81268, 81269, 81270, 81272, 81273, 81275, 81276, 81287, 81288, 81290, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81305, 81310, 81311, 81313, 81314, 81315, 81316, 81317, 81318, 81319, 81320, 81321, 81322, 81323, 81324, 81325, 81326, 81327, 81329, 81332, 81334, 81336, 81337, 81340, 81342, 81345, 81350, 81355, 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383, 81400, 81401, 81403, 81404, 81405, 81406, 81407, 81408, 81413, 81414, 81422, 81432, 81433, 81435, 81436, 81437, 81438, 81439, 81445, 81450, 81455, 81479, 81490, 81503, 81507, 81520, 81525, 81535, 81536, 81538, 81539, 81540, 81545, 81595, 81599, 83080, 83520, 84999, 88299, 88363, 0001U, 0004M, 0005U, 0006M, 0007M, 0011M, 0012M, 0012U, 0013M, 0013U, 0014U, 0016U, 0017U, 0018U, 0019U, 0022U, 0023U, 0026U, 0027U, 0029U, 0030U, 0031U, 0032U, 0033U, 0034U, 0036U, 0037U, 0040U, 0045U, 0046U, 0047U, 0048U, 0049U, 0050U, 0055U, 0056U, 0060U, 0069U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0078U, 0079U, 0087U, 0088U, 0089U, 0090U, 0094U, 0101U, 0102U, 0103U, 0111U, 0113U, 0114U, 0118U, 0120U, 0129U, 0130U, 0131U, 0132U, 0133U, 0134U, 0135U, 0136U, 0137U, 0138U, 0153U, 0154U, 0155U, 0156U, 0157U, 0158U, 0159U, 0160U, 0161U, 0162U

Radiation Therapy

Procedure/HCPCS Codes:

32701, 37243, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77301, 77338, 77371, 77372, 77373, 77385, 77386, 77424, 77425, 77432, 77435, 77469, 77520, 77522, 77523, 77525, 79445, G0339, G0340, G6015, G6016

Positron Emission Tomography (PET) Scans

Procedure/HCPCS Codes:

78608, 78811, 78812, 78813, 78814, 78815, 78816, A9515, A9552, A9580, A9587, A9588, A9597, A9598

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Outpatient Surgery & supplies

(Bariatric, Cosmetic, Vein Treatments, Orthognathic Surgery, UPPP, Deep Brain Stimulation, Gender Reassignment, Transplants)

Procedure/HCPCS Codes: 11403, 11920, 11921, 11922, 11950, 11951, 11952, 11954, 11960, 11970, 11971, 13152, 15775, 15776, 15780, 15781, 15782, 15783, 15786, 15787, 15819, 15820, 15821, 15822, 15823, 15824, 15825, 15826, 15828, 15829, 15830, 15832, 15835, 15839, 15847, 15877, 17106, 17107, 17108, 17999, 19300, 19316, 19318, 19324, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371, 19380, 19396, 21010, 21050, 21060, 21070, 21073, 21116, 21120, 21122, 21123, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21188, 21193, 21196, 21210, 21215, 21230, 21240, 21242, 21243, 21480, 21485, 21490, 29800 (w/ dx M26.4, M27.8, S01.409A, S01.409D, S01.409S, S03.0XXA, S03.0XXD, S03.0XXS), 29804 (w/ dx M26.4, M27.8, S01.409A, S01.409D, S01.409S, S03.0XXA, S03.0XXD, S03.0XXS), 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30520, 32850, 32851, 32852, 32853, 32854, 32855, 32856, 33930, 33933, 33935, 33940, 33944, 33945, 36468, 36470, 36471, 36475, 36476, 36478, 36479, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 38205, 38206, 38230, 38240, 38241, 38242, 40490, 40500, 40510, 40520, 40525, 40527, 40530, 40650, 41000, 41100, 41105, 41108, 41110, 41120, 41130, 41150, 41520, 42000, 42145, 42160, 42330, 42335, 42340, 43644, 43645, 43647, 43648, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43843, 43845, 43846, 43847, 43848, 43860, 43881, 43886, 43887, 43888, 43999, 44132, 44133, 44135, 44136, 44720, 44721, 44799, 47135, 47140, 47141, 47142, 47143, 47144, 47145, 47146, 47147, 47399, 48551, 48552, 48554, 61850, 61863, 61864, 61867, 61868, 61880, 61885, 61886, 61888, 64590, 64595, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67911, 67916, 67917, 67923, 67924, 69300, 76937, 93970, 93971, 95961, 95962, 95970, 95971, 95972, 95983, 95984

Stand-alone diagnosis codes

F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890 Observation Revenue Codes: 0762 Procedure/HCPCS Codes: 99218, G0378, G0379

Non-emergent Ambulance Services

(Air Ambulance)

Procedure/HCPCS Codes: A0430, A0431, A0435, A0436

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PRV8241 (1/21)

Procedure/Service

Comments

Durable Medical Equipment

Procedure/HCPCS Codes:

A9900, A9999, E0194, E0202, E0467, E0483, E0485 (with diagnosis

G47.30-G47.39), E0486 (with diagnosis G47.30-G47.39), E0617, E0619,

E0636, E0651, E0652, E0670, E0691, E0692, E0693, E0694, E0720, E0730, E0731, E0747, E0748, E0760, E0764, E0766, E0770, E0782, E0783, E0786, E1229, E1230, E1233, E1234, E1235, E1236, E1237, E1238, E1240, E1270, E1280, E1310, E1399, E1700, E1800, E1801, E1802, E1805, E1806, E1810, E1811, E1812, E1815, E1816, E1825, E1830, E1840, E1841, E2321, E2351, E2368, E2370, E2374, E2375, E2376, E2402, E2504, E2506, E2508, E2510, E2629, K0005, K0108, K0606, K0609, K0739, K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, K0822, K0823, K0824, K0825, K0827, K0828, K0831, K0835, K0840, K0843, K0848, K0849, K0850, K0852, K0853, K0854, K0855, K0856, K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0884, L8679, L8681, L8682, L8683, L8689, L8690, L8691, L8693, Q0479, Q0480, Q0481, Q0482, Q0483, Q0484, Q0489, Q0491, Q0495, Q0496, Q0503

Prosthetics and Orthotics

Procedure/HCPCS Codes: L0112, L0462, L0464, L0480, L0482, L0484, L0486, L0631, L0636, L0637, L0638, L0639, L0640, L0648, L0650, L0651, L0700, L0710, L0810, L0820, L0830, L0859, L1000, L1005, L1200, L1300, L1310, L1680, L1685, L1686, L1690, L1700, L1710, L1720, L1730, L1755, L1844, L1846, L1860, L1945, L2005, L2020, L2030, L2034, L2036, L2037, L2038, L2108, L2126, L2128, L2134, L2136, L2525, L2627, L2628, L3674, L3765, L3766, L3900, L3901, L3904, L3961, L3967, L3971, L3973, L3975, L3976, L3977, L3978, L4000, L4631, L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5400, L5420, L5500, L5505, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600, L5610, L5611, L5613, L5614, L5616, L5639, L5643, L5649, L5651, L5681, L5683, L5700, L5701, L5702, L5703, L5705, L5706, L5707, L5724, L5726, L5728, L5780, L5781, L5782, L5795, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5845, L5848, L5856, L5857, L5858, L5859, L5930, L5960, L5961, L5964, L5966, L5968, L5973, L5979, L5980, L5981, L5987, L5988, L5990, L5999, L6000, L6010, L6020, L6026, L6050, L6055, L6100, L6110, L6120, L6130, L6200, L6205, L6250, L6300, L6310, L6320, L6350, L6360, L6370, L6380, L6382, L6384, L6400, L6450, L6500, L6550, L6570, L6580, L6582, L6584, L6586, L6588, L6590, L6621, L6624, L6638, L6646, L6648, L6693, L6696, L6697, L6707, L6709, L6712, L6713, L6714, L6715, L6721, L6722, L6880, L6881, L6882, L6883, L6884, L6885, L6900, L6905, L6910, L6920, L6925, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965, L6970, L6975, L7007, L7008, L7009, L7040, L7045, L7170, L7180, L7181, L7185, L7186, L7190, L7191, L7259, L8035, L8040, L8041, L8042, L8043, L8044, L8045, L8046, L8047, L8499, L8609, L8614, L8616, L8619, L8627, L8628, L8631, L8659, L8699, L9900, V2623, V2624, V2626, V2627, V2628

CareFirst BlueCross BlueShield Advantage products are offered by CareFirst BlueCross BlueShield Medicare Advantage, the business name of CareFirst Advantage, Inc., a Maryland company and an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.

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Notice of Nondiscrimination and

Availability of Language Assistance Services

(UPDATED 8/5/19)

CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc., CareFirst Diversified Benefits and all of their corporate affiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex. CareFirst does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.

CareFirst:

■ Provides free aid and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters

Written information in other formats (large print, audio, accessible electronic formats, other formats) ■ Provides free language services to people whose primary language is not English, such as:

Qualified interpreters

Information written in other languages

If you need these services, please call 855-258-6518.

If you believe CareFirst has failed to provide these services, or discriminated in another way, on the basis of race, color, national origin, age, disability or sex, you can file a grievance with our CareFirst Civil Rights Coordinator by mail, fax or email. If you need help filing a grievance, our CareFirst Civil Rights Coordinator is available to help you.

To file a grievance regarding a violation of federal civil rights, please contact the Civil Rights Coordinator

as indicated below. Please do not send payments, claims issues, or other documentation to this office.

Civil Rights Coordinator, Corporate Office of Civil Rights

Mailing Address P.O. Box 8894

Baltimore, Maryland 21224

Email Address civilrightscoordinator@carefirst.com Telephone Number 410-528-7820

Fax Number 410-505-2011

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW

Room 509F, HHH Building Washington, D.C. 20201

800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., The Dental Network and First Care, Inc. are independent licensees of the Blue Cross and Blue Shield Association. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (used in VA by: First Care, Inc.). The Blue Cross® and Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.

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Foreign Language Assistance

Attention (English): This notice contains information about your insurance coverage. It may contain key dates

and you may need to take action by certain deadlines. You have the right to get this information and assistance in

your language at no cost. Members should call the phone number on the back of their member identification card.

All others may call

855-258-6518

and wait through the dialogue until prompted to push

0

. When an agent

answers, state the language you need and you will be connected to an interpreter.

አማርኛ

(Amharic)

ማሳሰቢያ፦

ይህ

ማስታወቂያ

ስለ

መድን

ሽፋንዎ

መረጃ

ይዟል።

ከተወሰኑ

ቀነ

-

ገደቦች

በፊት

ሊፈጽሟቸው

የሚገቡ

ነገሮች

ሊኖሩ

ስለሚችሉ

እነዚህን

ወሳኝ

ቀናት

ሊይዝ

ይችላል።

ይኽን

መረጃ

የማግኘት

እና

ያለምንም

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መብት

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ከሆኑ

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በስተጀርባ

ላይ

ወደተጠቀሰው

የስልክ

ቁጥር

መደወል

ይችላሉ።

አባል

ካልሆኑ

ደግሞ

ወደ

ስልክ

ቁጥር

855-258-6518

ደውለው

0

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እስኪነገርዎ

ድረስ

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መጠበቅ

አለብዎ።

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ወኪል

መልስ

ሲሰጥዎ፣

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ቋንቋ

ያሳውቁ፣

ከዚያም

ከተርጓሚ

ጋር

ይገናኛሉ።

Èdè Yorùbá (Yoruba)

Ìtẹ

́tíléko: Àkíyèsí yìí ní ìwífún nípa iṣẹ́ adójútòfò rẹ. Ó le ní àwọn déètì pàtó o sì le ní láti

gbé ìgbésẹ

̀ ní àwọn ọjọ́ gbèdéke kan. O ni ẹ̀tọ́ láti gba ìwífún yìí àti ìrànlọ́wọ́ ní èdè rẹ lọ́fẹ̀ẹ́. Àwọn ọmọ-ẹgbẹ́

gbọ

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́ a ó sì so ọ́ pọ̀ mọ́ ògbufọ̀ kan.

Tiếng Việt (Vietnamese)

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Tagalog (Tagalog)

Atensyon: Ang abisong ito ay naglalaman ng impormasyon tungkol sa nasasaklawan ng iyong

insurance. Maaari itong maglaman ng mga pinakamahalagang petsa at maaaring kailangan mong gumawa ng

aksyon ayon sa ilang deadline. May karapatan ka na makuha ang impormasyong ito at tulong sa iyong sariling

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identification card. Ang lahat ng iba ay maaaring tumawag sa 855-258-6518 at maghintay hanggang sa dulo ng

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at ikokonekta ka sa isang interpreter.

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Atención: Este aviso contiene información sobre su cobertura de seguro. Es posible que

incluya fechas clave y que usted tenga que realizar alguna acción antes de ciertas fechas límite. Usted tiene

derecho a obtener esta información y asistencia en su idioma sin ningún costo. Los asegurados deben llamar al

número de teléfono que se encuentra al reverso de su tarjeta de identificación. Todos los demás pueden llamar al

855-258-6518 y esperar la grabación hasta que se les indique que deben presionar 0. Cuando un agente de seguros

responda, indique el idioma que necesita y se le comunicará con un intérprete.

Русский (Russian)

Внимание! Настоящее уведомление содержит информацию о вашем страховом

обеспечении. В нем могут указываться важные даты, и от вас может потребоваться выполнить некоторые

действия до определенного срока. Вы имеете право бесплатно получить настоящие сведения и

сопутствующую помощь на удобном вам языке. Участникам следует обращаться по номеру телефона,

указанному на тыльной стороне идентификационной карты. Все прочие абоненты могут звонить по

номеру 855-258-6518 и ожидать, пока в голосовом меню не будет предложено нажать цифру «0». При

ответе агента укажите желаемый язык общения, и вас свяжут с переводчиком.

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हिन्दी

(Hindi)

ध्यान

दें

:

इस

सूचना

में

आपकी

बीमा

कवरेज

के

बारे

में

जानकारी

दी

गई

िै।

िो

सकता

िै

कक

इसमें

मुख्य

ततथियों

का

उल्लेख

िो

और

आपके

ललए

ककसी

तनयत

समय

-

सीमा

के

भीतर

काम

करना

ज़रूरी

िो।

आपको

यि

जानकारी

और

संबंथित

सिायता

अपनी

भाषा

में

तनिःशुल्क

पाने

का

अथिकार

िै।

सदस्यों

को

अपने

पिचान

पत्र

के

पीछे

हदए

गए

फोन

नंबर

पर

कॉल

करना

चाहिए।

अन्य

सभी

लोग

855-258-6518

पर

कॉल

कर

सकते

िैं

और

जब

तक

0

दबाने

के

ललए

किा

जाए

,

तब

तक

संवाद

की

प्रतीक्षा

करें।

जब

कोई

एजेंट

उत्तर

दे

तो

उसे

अपनी

भाषा

बताएँ

और

आपको

व्याख्याकार

से

कनेक्ट

कर

हदया

जाएगा।

Ɓǎsɔ́ɔ̀-wùɖù

(Bassa)

Tò Ɖùǔ Cáo! Bɔ ̃̌ nìà kɛ ɓá nyɔ ɓě ké m̀ gbo kpá ɓó nì fu ̀à-fṹá-tìǐn nyɛɛ jè dyí. Bɔ ̃̌ nìà kɛ

ɓéɖé wé jɛ́ɛ́ ɓě ɓɛ́ m̀ ké ɖɛ wa mɔ́ m̀ ké nyuɛɛ nyu hwɛ̀ ɓɛ́ wé ɓěa ké zi. Ɔ mɔ̀ nì kpé ɓɛ́ m̀ ké bɔ ̃̌ nìà kɛ kè

gbo-kpá-kpá m̀ mɔ́ɛɛ dyé ɖé nì ɓíɖí-wùɖù mú ɓɛ́ m̀ ké se wíɖí ɖò pɛ́ɛ̀. Kpooɔ̀ nyɔ ɓě mɛ ɖá fṹùn-nɔ̀ɓà nìà ɖé waà

I.D. káàɔ̀ ɖeín nyɛ. Nyɔ tɔ̀ɔ̀ séín mɛ ɖá nɔ̀ɓà nìà kɛ:

855-258-6518

, ké m̀ mɛ fò tee ɓɛ́ wa kéɛ m̀ gbo cɛ ɓɛ́ m̀ ké

nɔ̀ɓà mɔ̀à

0

kɛɛ dyi pàɖàìn hwɛ̀. Ɔ jǔ ké nyɔ ɖò dyi m̀ gɔ ̃̌ jǔǐn, po wuɖu m̀ mɔ́ poɛ dyiɛ, ké nyɔ ɖò mu ɓó nììn

ɓɛ́ ɔ ké nì wuɖuɔ̀ mú zà.

বাাংলা

(Bengali)

লক্ষ্য

করুন

:

এই

ননাটিশে

আপনার

ববমা

কভাশরজ

সম্পশকে

তথ্য

রশেশে

এর

মশযয

গুরুত্বপূর্ে

তাবরখ

থ্াকশত

পাশর

এবাং

বনবদেষ্ট

তাবরশখর

মশযয

আপনাশক

পদশক্ষ্প

বনশত

হশত

পাশর

ববনা

খরশে

বনশজর

ভাষাে

এই

তথ্য

পাওোর

এবাং

সহােতা

পাওোর

অবযকার

আপনার

আশে।

সদসযশদরশক

তাশদর

পবরেেপশের

বপেশন

থ্াকা

নম্বশর

কল

করশত

হশব।

অশনযরা

855-258-6518

নম্বশর

কল

কশর

0

টিপশত

না

বলা

পর্েন্ত

অশপক্ষ্া

করশত

পাশরন।

র্খন

নকাশনা

এশজন্ট

উত্তর

নদশবন

তখন

আপনার

বনশজর

ভাষার

নাম

বলুন

এবাং

আপনাশক

নদাভাষীর

সশে

সাংর্ুক্ত

করা

হশব।

( ودرا

Urdu

)

ہجوت

:

نکمم روا ںیہ یتکس وہ ںیخیرات یدیلک ںیم سا ۔ےہ لمتشم رپ تامولعم قلعتم ےس جیروک سنیروشنا ےک پآ سٹون ہی

ہچرخ ریغب روا ےنرک لصاح تامولعم ہی ساپ ےک پآ ۔ےڑپ ترورض یک ےنرک یئاورراک کت ںوخیرات یرخآ صوصخم وک پآ ہک ےہ

ناربمم ۔ےہ قح اک ےنرک لصاح ددم ںیم نابز ینپا ےیک

رگید یھبس ۔ےیہاچ ینرک لاک رپ ربمن نوف دوجوم رپ تشپ یک ڈراک یتخانش ےنپا وک

گول

855-258-6518

روا ںیہ ےتکس رک لاک رپ

0

نابز ہبولطم ینپا رپ ےنید باوج ےک ٹنجیا ۔ںیرک راظتنا کت ےناج ےہک وک ےنابد

۔ےگ ںیئاج وہ طوبرم ےس مجرتم روا ںیئاتب

( یسراف

Farsi

)

خیرات ات تسا مزلا و دشاب یمھم یاه خیرات یواح تسا نکمم .تسا امش همیب ششوپ هرابرد یتاعلاطا یواح هیملاعا نیا :هجوت

دینک تفایرد ناتدوخ نابز هب ناگیار تروص هب ار ییامنهار و تاعلاطا نیا ات دیتسه رادروخرب قح نیا زا امش .دینک مادقا یصاخ هدش ررقم

.

امش اب دیاب اضعا

ییاسانش تراک تشپ رد هدش جرد هر

هرامش اب دنناوت یم دارفا ریاس .دنریگب سامت ناش

855-258-6518

ددع دوش هتساوخ اھنآ زا ات دننامب رظتنم و دنریگب سامت

0

نابز ،اهروتارپا زا یکی طسوت ییوگخساپ زا دعب .دنهد راشف ار

دیوش لصو هطوبرم مجرتم هب ات دینک میظنت ار زاین دروم

.

ةغللا

ةیبرعلا

(Arabic)

هیبنت

:

يوتحی

اذه

راطخلإا

ىلع

تامولعم

نأشب

كتیطغت

،ةینیمأتلا

دقو

يوتحی

ىلع

خیراوت

،ةمھم

دقو

جاتحت

ىلإ

ذاختا

تاءارجإ

لولحب

دیعاوم

ةیئاھن

ةددحم

.

قحی

كل

لوصحلا

ىلع

هذه

ةدعاسملا

تامولعملاو

كتغلب

نودب

لمحت

يأ

ةفلكت

.

يغبنی

ىلع

ءاضعلأا

لاصتلاا

ىلع

مقر

فتاھلا

روكذملا

يف

رھظ

ةقاطب

فیرعت

ةیوھلا

ةصاخلا

مھب

.

نكمی

نیرخلآل

لاصتلاا

ىلع

مقرلا

855-258-6518

راظتنلااو

للاخ

ةثداحملا

ىتح

بلطی

مھنم

طغضلا

ىلع

مقر

0.

دنع

ةباجإ

دحأ

،ءلاكولا

ركذا

ةغللا

يتلا

جاتحت

ىلإ

لصاوتلا

اھب

متیسو

كلیصوت

دحأب

نیمجرتملا

نییروفلا

.

中文繁体

(Traditional Chinese)

注意:本聲明包含關於您的保險給付相關資訊。本聲明可能包含重要日期

及您在特定期限之前需要採取的行動。您有權利免費獲得這份資訊,以及透過您的母語提供的協助服

務。會員請撥打印在身分識別卡背面的電話號碼。其他所有人士可撥打電話 855-258-6518,並等候直到

對話提示按下按鍵 0。當接線生回答時,請

出您需要使用的語言,這樣您就能與口譯人員連線。

(8)

Igbo (Igbo)

Nrụbama: Ọkwa a nwere ozi gbasara mkpuchi nchekwa onwe gị. Ọ nwere ike ịnwe ụbọchị ndị dị

mkpa, ị nwere ike ịme ihe tupu ụfọdụ ụbọchị njedebe. Ị nwere ikike ịnweta ozi na enyemaka a n’asụsụ gị na

akwụghị ụgwọ ọ bụla. Ndị otu kwesịrị ịkpọ akara ekwentị dị n’azụ nke kaadị njirimara ha. Ndị ọzọ niile nwere

ike ịkpọ 855-258-6518 wee chere ụbụbọ ahụ ruo mgbe amanyere ịpị 0. Mgbe onye nnọchite anya zara, kwuo

asụsụ ị chọrọ, a ga-ejikọ gị na onye ọkọwa okwu.

Deutsch (German)

Achtung: Diese Mitteilung enthält Informationen über Ihren Versicherungsschutz. Sie kann

wichtige Termine beinhalten, und Sie müssen gegebenenfalls innerhalb bestimmter Fristen reagieren. Sie haben

das Recht, diese Informationen und weitere Unterstützung kostenlos in Ihrer Sprache zu erhalten. Als Mitglied

verwenden Sie bitte die auf der Rückseite Ihrer Karte angegebene Telefonnummer. Alle anderen Personen rufen

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Mitarbeiter die gewünschte Sprache an, damit er Sie mit einem Dolmetscher verbinden kann.

Français (French)

Attention: cet avis contient des informations sur votre couverture d'assurance. Des dates

importantes peuvent y figurer et il se peut que vous deviez entreprendre des démarches avant certaines échéances.

Vous avez le droit d'obtenir gratuitement ces informations et de l'aide dans votre langue. Les membres doivent

appeler le numéro de téléphone figurant à l'arrière de leur carte d'identification. Tous les autres peuvent appeler le

855-258-6518 et, après avoir écouté le message, appuyer sur le 0 lorsqu'ils seront invités à le faire. Lorsqu'un(e)

employé(e) répondra, indiquez la langue que vous souhaitez et vous serez mis(e) en relation avec un interprète.

한국어

(Korean)

주의

:

통지서에는

보험

커버리지에

대한

정보가

포함되어

있습니다

.

주요

날짜

조치를

취해야

하는

특정

기한이

포함될

있습니다

.

귀하에게는

사용

언어로

해당

정보와

지원을

받을

권리가

있습니다

.

회원이신

경우

ID

카드의

뒷면에

있는

전화번호로

연락해

주십시오

.

회원이

아니신

경우

855-258-6518

번으로

전화하여

0

누르라는

메시지가

들릴

때까지

기다리십시오

.

연결된

상담원에게

필요한

언어를

말씀하시면

통역

서비스에

연결해

드립니다

.

(Navajo)

855-258-6518

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