Wellness Visits and Screenings
  • Wellness Visits

    Liberty HealthShare encourages our members to see their Primary Care Physician or Provider yearly to maintain their health and well-being. After the first two (2) months of membership, an annual preventative wellness visit and related lab work for which there are no medical symptoms or diagnosis in advance are eligible for sharing, up to a maximum of $400 of the Fair and Reasonable charges as determined by Liberty HealthShare and not subject to the AUA nor subject to guideline limitations for medical expenses $200 or less.
    • a. Well baby visits including immunizations are eligible for sharing within the first 13 months after birth and not subject to the AUA or the two-month waiting period.
    • b. Any new condition based on symptoms discussed during your preventative wellness visit and any additional diagnostics or labs that are ordered to determine treatment are shareable according to Liberty HealthShare Sharing Guidelines and are subject to the AUA.
  • Screenings

    a. The following preventative screenings are not subject to the AUA:
    i. Screening pap smears are eligible for sharing once every year.
    ii. PSA tests, and Cologuard® are eligible for sharing once every two years up to and including age 49.
    iii. PSA tests, and Cologuard® are eligible for sharing once every year for members 50 years of age and older.
    iv. Screening mammograms are eligible for sharing once every year for women 40 years of age or older. .
    b. The following screenings are eligible for sharing and are subject to the AUA:
    i. Screening colonoscopies and bone density screenings
    ii. Ultrasound/MRI/Thermogram screening conducted in lieu of a screening mammogram
    iii. All diagnostic screenings
To submit a prenotification on behalf of a member, please enter the required information in the form below

Prenotification is NOT required for the following services:

  • CT Scans
  • Outpatient/Physician office visits
  • EKG
  • EGD
  • Emergency Department/Urgent Care visits
  • Plain X-Rays
  • Skin Biopsies
  • Ancillary Therapies
  • Screening & Diagnostic Colonoscopies
  • Routine Laboratory Testing
  • Screening & Diagnostic Mammograms
  • Ultrasounds
  • Wellness & Flu Vaccines
  • Chiropractic Care
  • Acupuncture
  • Complementary or Alternative Medical (CAM) Management
Tests where prenotification is not required are not necessarily eligible for sharing, based on the Sharing Guidelines

Prenotification Instructions: Please fax this cover sheet with Prenotification request Form along with all clinical information pertaining to this prenotification request.
 Clinical Information May Include: Current and previous physician notes, medical records, imaging, lab results, hospital admission information, treatment plans, ICD-10 codes, CPT codes, etc.
Maternity Prenotification: Please attach physician notes that include date of conception.
To be considered for medical cost sharing, the member MUST notify Liberty HealthShare IN ADVANCE by contacting the prenotification department for any services, procedures, and diagnostics listed below, except in the case of true emergencies. The Sharing Member, their physician, or their representative should contact the prenotification department as soon as the need for admission or services is recognized, and at least seven days prior to admission whenever possible.
Review time begins when ALL required medical records, treatment plans or other requested supportive documentation has been received.

If this is an urgent request, please call Liberty HealthShare at 855-585-4237, option 4.

Member Information
Female Male
Requesting Provider Information

Service Provider or Facility Information (Hospital, Surgery Center, etc.)

Prenotification Details

If applicable, please include ICD-10/CPT codes and their descriptions.


Attachments
Please attach documentation with a clear onset date of signs and symptoms (medical records, treatment plans, etc.)
 A 36-month pre-existing condition clinical review applies to members < 1 year.

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