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MEDICAL ASSOCIATES HEALTH PLANS AND HEALTH CHOICES

HEALTH CARE SERVICES POLICY AND PROCEDURE MANUAL

POLICY TITLE: AUTHORIZATION AND REFERRAL MANAGEMENT

POLICY STATEMENT:

Requests for services requiring authorization are reviewed according to member contract or plan

documents and established MAHP HCS Guidelines. These guidelines are viewed and approved

annually by the CMO, UMC, QIC, and Clinic Board of Directors. Authorizations may be

initiated or removed as deemed necessary by MAHP.

PURPOSE:

To ensure MAHP’s resources are utilized to deliver quality care to members in the most

appropriate and cost effective setting. MAHP will arrange for specialty care outside of the plan

provider network when network providers are unavailable or inadequate to meet an enrollee’s

medical need. Services and subsequent payment are based on the member’s benefit plan

document.

DEFINITIONS:

1. Pre-service decisions: a request for services that requires approval by MAHP, in whole or in

part, before the service can be rendered; a service that must be approved in advance before it

is rendered.

2. Post-service decisions (retrospective decisions): a service or claim which has already been

rendered. Occurs when notification is after the fact of care/service/delivery. The need for

“retro-review” is most often created by late or non-notification.

3. Concurrent review decisions: a review conducted during the course of treatment. Included,

but not limited to concurrent review is the anticipation and planning for post hospital needs,

arrangement for post hospital or acute treatment follow-up and support, ongoing review for

required disciplines.

4. Urgent pre-service decisions: Requires immediate action, although it may not be a life-

threatening circumstance an urgent situation could seriously jeopardize the life or health of

the covered member or the ability of the member to regain maximum function or in the

opinion of a physician with knowledge of the claimant’s condition would subject the member

to severe pain. An urgent care condition is a situation that has the potential to become an

emergency in the absence of treatment.

5. Emergent: Sudden or unexpected onset of server symptoms which indicate an illness or

injury for which treatment may not be delayed without risking the member’s life or seriously

impairing the member’s health.

REFERRAL AND AUTHORIZATION SUBMISSION OPTIONS:

Referral and authorization requests may be submitted to Health Care Services Case Management

and/or Utilization Management Nurses via telephone, fax, or electronically from members,

attending practitioners and/or facilities. Requests can also be submitted through the Cerner

Message Center, MAHP-HCS Pool.



REFERRAL REQUIREMENTS:

Commercial HMO, Community Health Plan (CHP) and IPlan: Referral authorizations are

required for any out of plan provider except for emergent care.

Medicare Smart and Community Health Plans: Referral authorizations are required for any out

of plan provider except for emergent care.

Point of Service (POS): Members have the option of utilizing two levels of benefits, authorized

or unauthorized. Members utilizing the authorized level of benefits are required to obtain a

referral from their in-network specialty care provider. Members may choose to obtain services

without a referral in or outside the MAHP network using their unauthorized benefits.

Medicare Freedom Plan: Members have the option of utilizing two levels of benefits, authorized

or unauthorized. Members utilizing the authorized level of benefits are required to obtain a

referral from their in-network specialty care provider. Members may choose to obtain services

without a referral outside the MAHP network using their unauthorized benefits.

Health Choices: Refer to specific plan document for referral requirements.

REFERRAL MANAGEMENT:

MAHP recommends that the referral request be obtained from an in plan provider of the same

specialty except on rare occasions. Only the initial consultative referral will be authorized

except when there is a predicted need for more visits or when the member is involved in an

ongoing process of care. In cases where a certain specialty is not available in-network, a

primary care provider may make the referral request for authorization to MAHP.

Following the initial consultation, additional referrals from the referring provider are required in

the following circumstances:

a. If the specialist wishes to provide additional services not originally requested on the

referral.

b. If the specialist refers member to a second specialist

c. If the specialty visits will exceed the number of visits initially authorized by MAHP

d. If the specialty visits require an extension beyond the referral thru date.

A standing referral for a member to utilize a non-participating physician or provider may be

issued if requested by an in plan and/or by request of a member with approval from the MAHP

CMO. The CMO shall consider the following in making an authorization for a referral:

a. Proposed treatment plan

b. Diagnosis

c. Ability of an in plan provider to provide the requested services

d. Frequency of needed care from the non-participating provider and/or



e. Continuity of care issues

Second and third opinions are covered when MAHP criteria are met.

a. Second opinions are covered according to the following:

The member has questions about the reasonableness or necessity of a recommended

surgical procedure;

The member has questions about a diagnosis or plan of care for a condition that

threatens loss of life, limb, or bodily function, or a serious chronic condition;

When a diagnosis is in doubt due to conflicting test results and the treating

practitioner is unable to diagnose the condition, or the clinical indications are

complex, unclear, or confusing;

When the current treatment plan is not improving the member’s condition;

When the member has attempted to follow a plan of care and has serious concerns

about the diagnosis or plan of care.

b. Third opinions are covered if the recommendations of the first and second physician

differ regarding the need for surgery or other major procedures/treatment.

c. All second and third opinions, whenever possible, should be provided in-network

and/or MAHP contracted provider and must be authorized by MAHP. (Unless

member has out-of-network benefits) Out-of-network second/third opinions may be

considered if there is no available or appropriate in-network/contracted provider and

must be authorized by MAHP’s Chief Medical Officer (CMO) or assigned physician

reviewer.

d. Second or third opinions may include:

A history and physical exam of the member

All diagnostic testing should be forwarded to the second or third opinion provider

or brought along with member to consult.

Any additional diagnostic testing required for determining the need for surgery and/or treatment

will require prior approval by the MAHP CMO or assigned physician reviewer.

NOTE: Referrals do not permit an out of plan specialist to refer members to another out of plan

specialist for care. If this is necessary, patients must get a referral from their referring in plan

provider to see another out of plan specialist. This referral is not a guarantee of payment.

Payment is subject to eligibility on date of service, plan benefits, limitations and exclusions, pre-

existing condition limitations, and patient liability under the plan. Referrals are time sensitive so

any date change requires notification to MAHP to update the referral.

PRIOR AUTHORIZATION:

Inpatient Services: All elective inpatient hospital admissions should be communicated to MAHP

for prior-authorization. Emergency hospital inpatient admissions do not require prior-

authorization but should be called or faxed to MAHP within 48 hours of the admission, or as

soon as the member is physically able to provide information for authorization.



Requests for Out-of-Area Urgent care require prior authorization. Emergent care will be

processed according to the limitations of the member’s contract or plan document, to the most

appropriate tier or at an in-network level.

Health plan members with students and/or dependents residing or attending school outside of the

MAHP service area may elect to participate in the “Care Package” program by completing the

attached form. (See appendix D) Participation in the program allows members to obtain in plan

benefits with requiring referral. If a member does not enroll their out-of-area dependent in the

“Care Package” program, only urgent and emergent coverage will be provided

Observation Services do not require prior authorization when provided at an in-network facility.

Authorization is required when services are being provided at an out-of-network facility and /or

when required per member’s plan contract or document. Services must be considered reasonable

and necessary to assess an outpatient condition to determine the need for inpatient admission or

discharge. Observation services should not be used for the convenience of the hospital, its

physicians, patients or patient’s families or while awaiting placement to another health facility.

Chiropractic services requested for MAHP and Health Choices members who do not have open

access coverage for chiropractic care, will require pre-certification according to the InterQual

Outpatient Rehabilitation & Chiropractic Criteria. All diagnostic tests, with the exception of x-

rays, and durable medical equipment must be ordered by the treating medical practitioner. Tests

not ordered by the treating medical practitioner will not be eligible for payment. NOTE: When

a MAHP Commercial and/or Health Choices member requires an authorized referral in order for

Chiropractic Services to be covered per their plan contract / document; the member must first

exhaust all internal resources prior to authorizing Chiropractic care, e.g. Physical Therapy,

Physiatrist, etc. Requests for chiropractic care outside of InterQual guidelines and/or extensions

beyond the suggested number of visits will be reviewed by physician reviewer.

All DME requests for items over $500 will be reviewed by the HCS Utilization Management

Nurse or Case Manager for appropriateness per the member’s contract/plan document and/or the

Health Care Services policies and procedures. If approval is given, an authorization is entered

into the system. Prior authorization for Health Choices requests are determined by each

individual plan document.

Note: If equipment cannot be supplied through the Health Plans’ network DME providers,

the Health Care Services Case Manager will work with providers to make arrangements to

obtain equipment. If the requested services are determined medically necessary, an

authorization is entered into the computer system to indicate coverage. The HCS Nurse will

negotiate fees when necessary.

The replacement of equipment is considered medically necessary only when documentation

shows that the current equipment/item is malfunctioning, cannot be refurbished and is no

longer under warranty.

See appendix A, B, C, and D for additional precertification and prior authorization requirements.



Authorization, referral and denial decisions are made in a timely manner that accommodates the

clinical urgency of the situation. Decisions are communicated to the requesting provider and

facility verbally and in writing within standard time frames. See HCS Decision Timeframes and

Determination Policy.

A quarterly report of authorized and denied/redirected services and out of plan referrals will be

presented to the Utilization Management Committee.

Documentation of referral requests will be kept on file for a minimum of three years in the

MAHP information system.

Repeated non-compliance of the Health Plans’ practitioner to the prior authorization and referral

procedures may result in corrective action by the Chief Medical Officer.

Appendix A: Pre-Certification Guidelines for Medical Associates Clinic

Appendix B: Health Choices Prior Authorization Requirements

Appendix C: Expansion Network Pre-Certification requirements

Appendix D: MAHP Pre-Certification Guidelines for out of network requests

Appendix E: Copy of “Care Package” form

Manager of Utilization Management Date

Director of Health Care Services Date

Original: 12/2015 Revised: 03/2017 Revised: 11/2017 Revised: 04/2018

Revised: 07/2018 Revised: 08/2019 Revised: 11/2019

Appendix A: Prior Authorizations-Medical Associates Health Plans

Revised: 08/2018

Commercial HMO/Community Plan



1. All In-patient stays require prior notification, with the exception of any in-patient services being provided

at Mercy Medical Center, Dubuque - no notification is necessary.

2. All skilled nursing stays require network provider following and prior authorization.

3. No authorization is needed for either same day surgeries or observations stays at in network facilities.

4. Sleep studies do not require authorizations when performed at in network facilities.

5. Specialty and Non-formulary medications, Remicade and other high dollar meds-utilize the Cerner

Message Pool

6. All Out of Plan referrals require prior auth, i.e. U/IA, UW - use Cerner Message Pool

7. CT’s/MRI’s/PET Scans being completed outside of MAC and utilizing a MAHP In-Plan Facility - no

authorization needed.

8. DME over $500 - use PA form from Internet

9. OT, PT, ST outside of MAC (Dubuque, Platteville or Galena) – treating facility responsible for Prior Auth.

10. InterStim procedure requires prior auth

11. Wireless Video Capsule endoscopy requires prior auth

12. Cologuard screening requires prior auth

13. Intone (DME over $500) requires prior auth

14. Home Health / Home infusion services require prior auth

15. Diabetic Education and Nutritional Counseling does not require authorization at in network facilities -

Diabetic Education available through Health Plan.

16. Genetic Testing, i.e. BRCA1 & BRCA2

Medicare (includes HMO, Community Plan and Freedom Plan)

1. All In-patient stays require prior notification, with the exception of in-patient services being provided at

Mercy Medical Center, Dubuque - no notification is necessary.

2. All skilled nursing stays must have in plan provider following and require prior authorization.

3. No authorization is needed for either same day surgeries or observations stays at in network facilities.

4. Remicade and other high dollar meds – utilize the Cerner Message Pool

5. All Out of Plan referrals require prior auth, i.e. U/IA, UW – utilize Cerner Message Pool

6. Sleep studies do not require authorizations when performed at in network facilities.

7. CT’s/MRI’s/PET Scans being completed outside of MAC and utilizing a MAHP In-Plan Facility - no

authorization needed.

8. No authorization is needed for OT, PT, and ST when service is ordered by and provided by an in-plan

provider. Aquatic Therapy requires authorization.

9. DME over $500 – use prior authorization form located on Intranet

10. InterStim procedure requires prior auth

11. Wireless Video Capsule Endoscopy requires prior auth

12. Cologuard screening require prior auth

13. Intone (DME over $500) requires prior auth

14. Diabetic Education and Nutritional Counseling does not require authorization at in network facilities -

Diabetic Education available through Health Plan.

15. Genetic testing requires prior auth, i.e. BRCA1 & BRCA2

***DME items less than $500 that requires prior authorization are as follows:

Pulse oximeters

Seat lift mechanisms

CPM machines

Apnea Monitors

Diabetic shoes

Insulin pump supplies (Quarterly)

PT/INR Home Monitoring Device

The preferred MRI & CT unit is at the Medical Associates Clinic and members are to be directed to the Medical

Associates Campus for the MRI & CT’s to be performed whenever possible. MRI’s & CT’s performed outside

of Medical Associates Clinic are medically necessary when one of the following are met:



1. Emergency/urgent situation

2. When a timely MRI or CT are not available at an in-plan facility

3. Member need – inability to travel due to illness, injury, physical disability etc.

4. Unable to obtain procedure at in-plan facility i.e. stereotactic MRI, CTA

In network facilities include: MAC, Mercy Dubuque and Dyersville, Finley Hospital, SW Health Center,

Memorial Hospital of Lafayette, Grant Regional, Midwest Medical Center in Galena, Jones Regional Medical,

Jackson County Public Hospital, Gundersen Boscobel Area Hospital and Clinics, Upland Hills Health-

Dodgeville, Guttenberg Municipal Hospital, Regional Medical Center, Crossing Rivers Medical Center, Central

Community Hospital, Tri-State Surgery.

Health Choices Prior Authorization Requirements Pre certification may be required and is not limited to the following, please contact Health Choices at (866) 390-

3872 or (563) 584-4783 for specific Plan requirements:

*** ALL groups require In-patient notification with the exception of in-patient services being provided at

Mercy Medical Center, Dubuque - no notification is necessary.

Bodine Electric – 990048

Pharmacy Benefits – Medical Associates Health Plans (ED med.- Benefit Exclusion)

All DME over $500

All Inpatient Admissions including Rehab and Long Term Acute Care

All Out of Network services and Referrals (except urgent and emergent)

Bariatric Surgery

Chemotherapy

Dental or oral surgical services

Enteral or parenteral feeding

Genetic Testing

High cost radiology tests (CT/CTA, MRI/MRA, PET Scan)

Home Health (nursing, therapy, home infusions, etc.)

Organ Transplants

Outpatient Therapies, i.e. physical therapy, occupational therapy, and speech therapy

(after 20 combined visits)

Panniculectomy

Prosthetics if purchase price is over $500

Reconstructive Surgery, including those resulting from accident or disease

Radiation Therapy

Reduction Mammoplasty

Residential Care Facility (Mental Health or Substance Abuse)

Skilled Nursing Facility

Surgical and non-surgical treatment of TMJ (Temporomandibular Joint Disorder)

Wound VAC therapy

Dupaco – 990054 (Point of Service)

Pharmacy Benefits – MedOne 888-884-MED1

All DME over $500




Bariatric Surgery

Chemotherapy

Cochlear Implants

Cosmetic/Reconstructive Surgery, including those resulting from accident or disease





Infertility – benefit limitations apply

IV Drug Therapy (In office or Hospital setting)

Organ Transplant

Panniculectomy

Radiation Therapy


Residential Care Facility


Wound VAC Therapy

Giese – 99038 (Point of Service)

Pharmacy Benefits – Medical Associates Health Plans

All DME over $500


Bariatric Surgery



Dependents Out of Network (services paid in network with authorization from Health

Choices)


Genetic Testing

Growth Hormones

Hemodialysis


Hospice

Organ Transplants

Out of Network Referrals

Outpatient Therapies, i.e. physical therapy, speech therapy and occupational therapy

(after 20 visits)

Panniculectomy


Skilled Nursing Facility Services

Wound VAC Therapy

IBEW – Out of Network Benefits

Please contact Health Choices at (866) 390-3872 or (563) 584-4783 for specific Plan

requirements and Kunkel Care Solutions at (855) 558-2310 for Prior Authorization.




All DME over $500

All Inpatient Admissions

o Skilled Acute

o Long-term Acute Care

o Nursing Facilities

o Psychiatric and Substance Abuse

All Out of Network Referrals and Second and/or Third opinions

All Outpatient Surgeries

Bariatric Surgery

Chemotherapy

Cochlear Implants


Diabetic Shoes, orthotics and/or modifications to the shoes

Dialysis


Genetic Testing



Hospice

Infertility

Organ Transplants

Osseointegrated Implants



Radiation Oncology



Sleep Apnea Treatment

Wound VAC Therapy

Medical Associates Clinic – HC0006


All DME over $500




All Out of Network services and Referrals (except urgent and emergent)

Bariatric Surgery

Chiropractic Services



Diabetic Shoes


Hospice

Infertility (no coverage for IVF)

Insulin pumps and supplies (initial request and every 3 months after approval)

Organ Transplants

Outpatient Therapies not provided at Medical Associates Clinic, i.e. physical therapy,

speech therapy and occupational therapy

Panniculectomy




Wound VAC therapy

MercyOne Dubuque– HC0005 (Point of Service)

Pharmacy – CVS/Caremark (800)552-8159

All DME over $500


All Out of Network Referrals

Bariatric Surgery


Habilitation services

Mental Health Care and Substance Abuse – Partial Hospitalization, Intensive Outpatient,

Outpatient psychiatric testing, Residential Treatment

Organ Transplants

Pain Clinic (Finley)

Panniculectomy


Radiation Oncology – Wendt Center Tier 2 with pre certification approval



Wound VAC Therapy

Rite Hite – 990036 (Point of Service)


All DME over $500



All Out of Network Referrals

Diagnostic Imaging – Ambulatory

o CT Angiogram

o CT Calcium Screening

o MRI of the heart

o Capsule Camera Endoscopy

o Virtual Colonoscopy

o Oncology related PET, CT, or MRI

Infusion Services – Home and Office

Inpatient Services (Medical, Surgical, Behavioral)

o Elective Admissions, Emergency Admissions, Skilled Nursing Facility

Admissions, Transplants

Outpatient Therapies (Visits in excess of 25 require Medical Necessity Review), i.e.

physical therapy, speech therapy and occupational therapy


Surgical Procedures – Ambulatory

o Abdominoplasty

o AICD and Biventricular device insertions

o AV Fistula or graft access for dialysis

o Bariatric (weight loss) Surgery

o Blepharoplasty

o Breast Reduction

o Excess skin removal arms, chest and legs

o Hysterectomy

o Maxillo-facial surgery

o Nasal Surgeries

o Orthopedic Surgeries with implants

o Panniculectomy

o Sclerotherapy

o Shock Wave Lithotripsy plantar fasciitis

o Spinal Surgeries

o UP3/UPPP – Uvulopalopharyngoplasty

o Varicose Vein Treatment (Sclerotherapy, Stripping or Endovenous Ablation)

o Ventral Hernia Repair

o Back or neck procedures (Intradiscal Electrothermal Annuloplasty (IDET),

Percutaneous Radiofrequency Neurotomy, Artificial Intervertebral Disk

Implantation, Automated Percutaneous Lumbar Diskectomy (APLD)

Wound VAC Therapy

SWWI Schools – 990039


All DME over $500




Bariatric Surgery

Cochlear Implants

Hearing Aids – Children under 18 years of age.

Organ Transplants

Panniculectomy




Speech Therapy

Treatment of Sleep Apnea

Wound VAC Therapy

Appendix C: Pre certification may be required for the following, please contact Medical Associates Health Plans at (866) 821-

1365 or (563) 584-4885 for plan specific requirements:

All DME over $500


All Same Day Surgeries requiring an overnight stay

Apnea Monitors

Bariatric Surgery

Blepharoplasty

Chemotherapy

Cochlear Implants

CPM Machines


Diabetic Shoes


Gender Reassignment

Genetic Testing

High cost radiology tests (CT/CTA, HIDA Scan, MRI/MRA, PET Scan, Ultrasound)


Hospice

Hyperbaric Oxygen Treatment

Hysterectomy (Vaginal or Abdominal)

Implantable Bone Conduction Hearing Device

Insulin pumps and supplies (initial request and every 3 months after approval)

Neuroablation

Nutritional Counseling, including Diabetic Education


Panniculectomy

PT/INR Home Monitoring Device

Pulse Oximeters


Radiation Oncology

Reduction Mastectomy


Rhinoplasty

Seat Lift Mechanisms

Skilled



Sleep Studies

Joint Replacements

Transcranial Magnetic Stimulation

Varicose Vein Treatment (Sclerotherapy, Stripping or Endovenous Ablation)

Wound VAC therapy

Appendix D: MAHP pre-certification guidelines for out of network requests include and may not be limited to the following:

a. Routine care out-of-area is not a covered service. Routine care is defined as treatment for a condition

which the patient has prior to leaving the service area. Medicare members: authorization will be granted

for medical services when requested by treating in-network physician/provider for members with ongoing

medical needs who will be out of service area. Examples include pro times for members on blood

thinners, dialysis out of service area, physical therapy etc. An authorization for these services will be

entered into the information system.

b. Routine lab work regularly scheduled to occur is not covered while out of the service area unless

medically necessary to maintain the member’s health. An exception can be made and an authorization

entered into the system.

c. Eye exams for students will be authorized if the patient is having acute symptoms such as headaches or

blurry vision. Routine eye exams will be authorized out-of-area if no appointment within the Health

Plans’ service area can be made for the patient within a four-week period. Payment will be made

according to the contract limitations.

d. Elective procedures such as, but not limited to repeat pap smears in follow-up to previous abnormal pap

smears, colposcopies are not covered out-of-area. If it is felt to be more urgently needed, a copy of pap

smear report will be obtained for review by the Chief Medical Officer.

e. Treatment of sexually transmitted diseases for student’s out-of-area will be approved for initial evaluation

with a request for a treatment plan from the treating practitioner. Upon review of the treatment plan,

subsequent follow-up visits will be authorized based upon the reasonableness of the treatment plan, with

the understanding that the student will follow-up with a Health Plans’ provider upon return to the service

area.

f. Follow-up care will be authorized as necessary, when it is not reasonable for the patient to return to the

service area and/or a considerable unsuccessful attempt has been made to obtain an appointment for the

patient upon return to the service area. If an appointment can be arranged for the patient in the service

area, but the patient refuses, the visit will not be authorized out-of-area.

g. Allergy injections – College students will be directed to Student Health facilities. Authorizations will

need to be entered for claims to pay. Adults needing allergy injections out of the services area will

require an In-Plan Physician referral indicating medical necessity and time frame needing approval. An

authorization will be entered when medically indicated.

h. Vaccination Exception: Meningitis Vaccine is covered for college students at Student Health

Departments. Hepatitis B Vaccine is covered for college students at Student Health Departments (if

covered in contract). No referral is necessary. Schools are to submit bills to the Health Plans for

reimbursement.

i. Physical Therapy may be authorized out-of-area when in follow-up to treatment initiated by a

participating practitioner and the treating provider requests authorization for the service. Physical

Therapy will be authorized in follow-up to treatment initiated by non-participating practitioners out-of-

area when the incident/illness/injury occurs while out of the Health Plans’ service area.

j. Requests for mental health/chemical dependency services by all enrollees will be directed to their

designated mental health triage group i.e. HMO (open access) members are referred to Medical Associates

HCS Department. HCS Policy Mental Health / Chemical Dependency Access Standards is utilized to

determine coverage on non-participating providers. Information is entered into MAHP’s computer system

and treatment plans are requested as needed.

k. Members receiving kidney dialysis and who have a short-term need (two weeks or less) out of the services

area my request consideration of coverage for kidney dialysis while out of the service area. Requests

should be provided by the treating Nephrologist with pertinent information such as, treating facility and

length of stay. The Case Manager may authorize dialysis when appropriate.



Appendix E:



Appendix F:

Suggested Guidelines for Outpatient Nutrition Visits

The below guidelines are suggested number of visits for nutritional counseling. Approving additional

visits over the suggested amount should be based medical necessity, the provider’s plan of care, the

dietician and member needs. Visits can be spanned over a 3 month period of time.

Low Cholesterol Diet 2 visits

Lower Cholesterol with other modifications* 2 visits

Sodium Restriction Diet 2 visits

Sodium Restriction with other modifications* 2 visits

Diabetic Diet 2 visits

Diabetic Diet with other modifications* 3 visits

Gestational Diabetes 2 visits

Hypertriglyceridemia 1 visit

Hypertriglyceridemia with other modifications* 2 visits

Eating Disorders (anorexia nervosa, bulimia) 4 visits

High Fiber Diet 1 visit

Low Residue 1 visit

Low Fat (gallbladder) 1 visit

FODMAP Diet (IBS diet) 2 visits

*Modifications could include a combination of one or more dietary needs (i.e. Sodium, low cholesterol,

low carb, high fiber)

medical associates health plans and health choices health … · note: if equipment cannot be...

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