QualityPath Benefit Details Procedure: Knee and Total Hip Replacement

Providers:

View list of providers performing knee and total hip replacements

Notification requirements:

Call The Alliance Patient Experience Manager at 800.223.4139 x6607 prior to scheduling services.

Services covered at the QualityPath level of benefits:

  • The initial consultation with the QualityPath surgeon
  • Pre-operative testing including:
    • Lab tests
    • X-rays & imaging
    • Pre-operative physical
    • Other tests that are determined to be medically necessary
  • One physical therapy visit done for the purpose of preparing for surgery
  • Joint class provided by the QualityPath provider
  • Services provided on an inpatient basis including:
    • hospital daily room charges & facility fees
    • surgeon’s fee
    • assistant surgeon fee
    • anesthesia
    • pathology
    • radiology charges associated with the procedure
    • physical therapy/occupational therapy other medical professionals, including hospitalists and other specialists as medically indicated
  • Post-operative care for 90 days after the surgery including:
    • lab fees to monitor therapeutic level of blood thinner as ordered by physician
    • Outpatient physical therapy performed by a the QualityPath provider, in a QualityPath hospital or clinic
    • Home health, including:
      • physical therapy
      • nursing care associated with initial assessment for physical therapy
      • nursing care associated with medication management, including lab fees

NOTE: please see warranty for information regarding complications.

Warranty:

Services under the warranty are covered under the QualityPath level of benefits. The warranty period begins the day of admission and continues through the 90-day episode-of-care. The warranty covers the following care related to the QualityPath surgery:

  • Hospital readmission and reoperation: during the 90-day episode-of-care
  • Other treatment of complications: during the 90-day episode-of-care

Patient requirements to maintain the warranty include:

  • Receiving all follow-up care from the QualityPath provider, excluding necessary emergency care.
  • Complying with all post-discharge instructions, including attending outpatient physical therapy sessions as well as completing the prescribed home exercises.

Exclusions:

The following services are not eligible for the QualityPath level of benefits. Check with your benefits administrator for coverage levels under the standard health plan benefits.

  • All services provided by a non-QualityPath provider (Outpatient physical therapy services and some home health care by an Alliance contracted provider may be covered at the QualityPath level of benefits. Check your SPD for details regarding physical therapy.)
  • Post-discharge care that is unrelated to the procedure
  • Skilled nursing facilities, unless for bilateral joint replacement surgery
  • Unrelated readmissions during warranty period
  • Coverage for the same procedure during the warranty period, when not due to complications related to the initial procedure
  • Care related to the procedure rendered outside the 90-day warranty period
  • Services provided by a QualityPath provider performed prior to member’s enrollment in the program
  • Rehabilitation services outside the physician care plan
  • Services provided inpatient unrelated to the QualityPath procedure
  • Durable medical equipment

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