what is self referral and what are the covered service under self referral?

Self-Referral Services

Self-referral services are defined in the HealthChoice regulations as “health care services for which under specified circumstances the MCO is required to pay without any requirement of referral or authorization by the primary care provider (PCP) or MCO when the enrollee accesses the services through a provider other than the enrollee’s PCP.”

The following services must be reimbursed by the MCO without a referral:

Child With Pre-Existing Medical Condition - Medical Services

Child In State-Supervised Care - Initial Medical Exam

 Emergency Services Family Planning Services

HIV/AIDS Annual Diagnostic and Evaluation Service Visit

Newborn’s Initial Medical Examination In A Hospital

Pregnancy-Related Services Initiated Prior To MCO Enrollment

Renal Dialysis Services Provided In A Medicare Certified Facility

School-Based Health Center Services Substance Abuse Assessment

For additional information regarding the above self-referral services contact the Division of Outreach Care and Coordination at 410-767-6750/6859.

Simply health care - services required authorization

All of the following procedures and services require Prior Plan Notification and must be

provided in a SHP participating facility

o Inpatient and Observation Admissions, as noted above

o Admission to any rehabilitation and skilled nursing facility

o All surgical procedures, inpatient or outpatient

o The following have special reporting requirements (refer to Forms Section):

 Abortions

 Hysterectomies

 Sterilization procedures

o Cosmetic or Reconstructive Surgery, including but not limited to:

 Breast reconstruction or reduction

 Blepharoplasty

 Venous procedures

 Sclerotherapy

o Services and items:

 Allergy (immunotherapy), exept for those services identified on the QAF

 Ambulance transportation (non emergent)

 Amniocentesis

 Cardiac and pulmonary rehabilitation programs

 Circumcisions after 12 weeks of age

 Court-ordered services

 Chemotherapy

 Dialysis

 DME, including apnea monitors and bili-blankets

 Upper endoscopies at colonoscopies at hospitals

 Genetic testing

 Gamma Knife, Cyberknife

 Hearing aids

 Home Health Services

 Hospice care

 Hyperbaric Oxygen Therapy (HBO)

 Investigational and experimental procedures and treatments

 IV Infusions

 Laboratory services in POS 22 and 24

 Lithotripsy

 Mental Health (See Mental Health Section)

 Nutritional counseling

 MRI’s, MRA’s

 Oral Surgery

Quick Authorization Form (QAF)

For those services included on the SHP Quick Authorization Form (QAF) (see the Forms Section of this handbook) a referral is NOT required. Primary Care Physicians (PCP’s) can refer a member to a  participating specialist and to many frequently requested services and procedures at free-standing facilities with the Simply Healthcare Plans Quick Authorization Form (QAF) without contacting the health plan for prior authorization.

IMPORTANT NOTE: Communication with the Plan prior to the provision of care is not necessary when using the QAF; however, all inpatient services, outpatient hospital services (including diagnostics), and ASC services do require an authorization

Prenatal care referrals are NOT to be made using the QAF.

**The QAF form is not valid for any inpatient or outpatient hospital services or for any consultations or procedures not listed on the form, or for out-of-network providers.**

The PCP or specialist ordering the consultation or test is required to fax or mail a copy of the  completed QAF to the participating provider or facility that will be providing the service(s), or to give a copy to the member so that it is presented at the time of the service

Services that Do NOT Require Prior Authorization or QAF:

 Family Planning

 Participating Office/free standing laboratory tests at labs consistent with CLIA guidelines

 Emergent transportation services

How to avoidReferral/Prior Authorization Request Delays or rejection

The following guidelines will help expedite your referral and authorization requests:

•     Submit an online request or, if that option is not available to you, use the TRICARE Patient Referral/Authorization Form for any TRICARE Prime beneficiary requiring a specialty care referral or a prior authorization for any TRICARE West Region beneficiary who requires prior

authorization for services on the Prior Authorization List

     Submit complete online referral and authorization requests with physician documentation and all clinical indications, including laboratory/ radiology results related to the requested service. Attach relevant documentation to your online request. If you have an electronic medical management system, you may also copy/paste from that system into your online request. If you are unable to submit your requests online, submit a complete and legible TRICARE

Patient Referral/Authorization Form by fax.

•     If you submit referrals and authorizations online on a regular basis, please use a Request Type profile that includes your requested codes.

* TriWest has online user guides to help you select the correct Request Type profile. TriWest has more than 100 profiles and using them will eliminate any code range issues. If you cannot use a profile, TriWest limits code ranges (low and high) to 10 codes. If the code range is more than 10 codes, the user will get an error indicating that the “allowable” code range has been exceeded and will have to put in a code range less than 10 codes. The user will not be able to enter the request until there is an acceptable code range.

•     Be specific about the requested services and provide the most appropriate procedure and  diagnosis codes. Requests for DME also require complete information on applicable codes. A reasonable range is acceptable.

Include National Drug Codes (NDCs) for medication requests.

•     Make sure the correct ICD-9 and Current Procedural Terminology (CPT®) code(s) are included. Include clinical documentation for services on the Prior Authorization List.

Be sure to clearly reference your contact information, particularly the fax number to which TriWest should respond. Incomplete

forms may slow the process.

•     When pictures are needed to support the requested service, the preferred method of submission is to use the online referral and authorization tool

and attach a digital photograph to the request.

Pictures sent via fax do not transmit clearly and may delay the process while

TriWest requests and awaits receipt of originals.

•     Generally, approvals are active for 180 days, unless otherwise indicated on the referral/ authorization approval letter. If the servicing provider is unable to provide the approved services prior to the expiration of the referral,

a new referral/authorization request must be submitted. If it has been 180 days or more since the initial approved request for the same diagnosis, the PCM should request the new referral/authorization. If the specialist has obtained a referral from the PCM within 180 days, the specialist may make the request

for services related to the same diagnosis.

If the servicing provider wishes to add additional procedural or treatment codes to the approved referral or authorization, then a new referral/

authorization request must be submitted covering the additional requested services.

•     Verify the beneficiary’s demographic information (sponsor’s Social Security number, address, date of birth, etc.) and include it on the request form.

•     When using the fax process, you only need to fax your referral or authorization request once, if you have confirmed that you faxed the referral

to the correct number and have a confirmation from your fax machine. Re-faxing creates duplicate requests and delays processing. You may check the status of your request online at any time if you are registered with

www.triwest.com/provider, regardless of whether the request was submitted online or by fax. You may also call 1-888-TRIWEST (1-888-874-9378) if you have not received a response within five days.

Does Medicare Tricare beneficiary require authorization

Beneficiaries Using Medicare and TRICARE

Beneficiaries using Medicare as their primary payer are not required to obtain referrals or prior authorization from TriWest for inpatient or outpatient behavioral health care services. These beneficiaries should follow Medicare rules for services requiring authorization. They may self-refer to any network or non-network provider who accepts Medicare. When behavioral health care benefits are exhausted under Medicare, TRICARE becomes the primary payer, and prior authorization from TriWest is then required.

For more information, contact the Medicare Plan Administrator at 1-800-633-4227.

Authorization process for Tricare standard, extra and list of services

Beneficiaries Using TRICARE Standard and TRICARE Extra, TRICARE Reserve Select, or TRICARE Retired Reserve

Beneficiaries using TRICARE Standard and TRICARE Extra, TRS, or TRICARE Retired Reserve (TRR) generally do not need referrals and can receive their first eight outpatient visits without prior authorization to diagnose and/ or treat behavioral health components of an otherwise diagnosed medical or psychological condition. Services provided by a licensed or certified mental health counselor or pastoral counselor require physician referral and supervision.


Upon the first visit, providers may check eligibility, if registered, at www.triwest.com/provider or call 1-888-TRIWEST (1-888-874-9378) for eligibility verification or other questions. It is important to note that the first eight visits are per beneficiary, not per provider. Ask the beneficiary
if he or she has received previous behavioral health care.

After the first eight self-referred outpatient visits, prior authorization is required. Servicing providers must submit authorization requests online at www.triwest.com/provider, after registering, or complete and fax a Preauthorization for Outpatient Treatment Request form to 1-866-269-5892. The request will be reviewed to determine whether continuing care meets
InterQual criteria. No additional sessions are authorized until the treatment request is reviewed.

Pregnancy service - prior authorization information

Pregnancy

PCP’s or obstetricians are required to notify SHP of the first prenatal visit and/or positive pregnancy test within two (2) working days by completing the Pregnancy Notification Form (refer to the Forms Section), whether the pregnancy was identified through medical history, examination, testing or otherwise.

SHP will allow pregnant enrollees to choose in-network obstetricians as PCP’s if the obstetrician is willing to participate as a PCP.

If a pregnant member has not selected a PCP for her unborn child, SHP will assign a pediatrician for the care of their newborn babies no later than the beginning of the last trimester of gestation. If a provider treating a pregnant member for prenatal care decides to terminate the contract with the Plan, SHP will allow the  member to continue care with that provider until completion of the postpartum care.

Does Emergency Services require Authorization ?

Emergency Services

Emergency services are not subject to prior authorization requirements and are available to our members 24 hours a day, seven days a week, 365 days a year.

An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain or other acute symptoms, such that a prudent lay person who possesses an average knowledge of health and medicine could reasonably

expect that the absence of immediate medical attention could reasonably be expect to result in any of the following:

*  Serious jeopardy to the health of the member, including a pregnant woman or fetus

*  Serious impairment to bodily functions

*  Serious dysfunction of any bodily organ or part

*  A pregnant woman having contractions

SHP shall not:

*  Require prior authorization for an enrollee to receive pre-hospital transport or treatment or for emergency services and care;

*  Deny payment for treatment obtained when a representative of the SHP instructs the enrollee to seek emergency services.

*  Specify or imply that emergency services and care are covered by the Plan only if secured within a certain period of time;

*  Use terms such as "life threatening" or "bona fide" to qualify the kind of emergency that is covered; or

*  Deny payment based on a failure by the enrollee or the hospital to notify SHP before, or within a certain period of time after, emergency services and care were given.

*  Deny claims for emergency services and care received at a hospital due to lack of parental consent.

Pre-hospital and hospital-based trauma services and emergency services and care will be authorized.

SHP shall cover all screenings, evaluations, and examinations that are reasonably calculated to assist the provider in arriving at the determination as to whether the member has an emergency medical condition. If the provider determines that an emergency medical condition does not exist, SHP is not required to cover services rendered subsequent to the provider's determination unless

authorized by the Plan.

If the provider determines that an emergency medical condition exists, and the enrollee notifies the hospital or the hospital emergency personnel otherwise have knowledge that the patient is an enrollee of SHP, the hospital must make a reasonable attempt to notify the enrollee's PCP, if known, or SHP, if the Plan has previously requested in writing that it be notified directly of the

existence of the emergency medical condition

If the hospital, or any of its affiliated providers, do not know the enrollee's PCP, or have been unable to contact the PCP, the hospital must notify SHP as soon as possible before discharging the enrollee from the emergency care area; or notify the Plan within twenty four (24) hours or on the next business day after the enrollee’s inpatient admission.

Understand Prior Authorization - Full details

Prior Authorizations:

Prior authorization (pre-service requests) allows for the use of quality, cost-efficient covered health care services and helps to ensure that effective transition of care planning is done so that members receive the most appropriate level of care within the most appropriate setting. Prior authorization must be obtained for all services not included on the Quick Authorization Form (QAF) for PCP’s (see section above) that require an authorization.

SHP’s UM Department evaluates requests for services/procedures and makes determinations based on medical necessity, covered benefits and appropriateness based on SHP’s approved utilization criteria (Interqual) and evidence-based, nationally recognized clinical guidelines. Only a Medical Director may issue an adverse determination, with the exception of denials due to benefit issues. No provider or any other individual or SHP employee or associate is rewarded for issuing denials of coverage or care. Financial incentives will NOT encourage decisions that would result in underutilization nor are incentives to create barriers to care and services.

Prior Authorization Requests are to be made through the SHP’s UM Pre-Certification Department.

Prior Authorization or Notification Process:

*  Providers are to fax the Referral & Authorization Form (refer to Forms Section) to the SHP’s Utilization Management Pre-Certification Department at Fax number 1-800-283- 2114 or by calling the PreCertification Telephone Queue 1-800- 887-6888, ext 2271.

*  Routine (NOT STAT/URGENT) requests are processed within fourteen (14)

calendar days of the Plan receiving the authorization request and having received all supporting clinical information.

STAT/URGENT requests are processed within seventy-two (72) hours of the Plan receiving the request and having received the supporting clinical information.

NOTE: STAT/URGENT Authorizations should be CALLED IN to the SHP Pre-Certification Authorization Telephone Queue and NOT faxed, and the caller should identify the request as “STAT/URGENT”. These requests should always meet the defined medical criteria for such which are:

STAT/URGENT: Any condition where failure to issue an immediate response may result in an IRREVERSIBLE SIGNIFICANT, ADVERSE outcome of health and/or function.

*  Each Referral & Authorization Form received from the provider’s offices will be date and time- stamped, manually or electronically and is reviewed for completeness, eligibility, benefits, PCP and specialist network affiliation

List of procedure - Authorization required

All of the following procedures and services require Prior Plan Notification and must be provided in a SHP participating facility*:

o Inpatient and Observation Admissions, as noted above
o Admission to any rehabilitation and skilled nursing facility
o All surgical procedures, inpatient or outpatient

o The following have special reporting requirements (refer to Forms Section):
*  Abortions
*  Hysterectomies
*  Sterilization procedures

o Cosmetic or Reconstructive Surgery, including but not limited to:
*  Breast reconstruction or reduction
*  Blepharoplasty
*  Venous procedures
*  Sclerotherapy

o Services and items:
*  Allergy (immunotherapy), exept for those services identified on the QAF
*  Ambulance transportation (non emergent)
*  Amniocentesis
*  Cardiac and pulmonary rehabilitation programs
*  Circumcisions after 12 weeks of age
*  Court-ordered services
*  Chemotherapy
*  Dialysis
*  DME, including apnea monitors and bili-blankets
*  Upper endoscopies at colonoscopies at hospitals
*  Genetic testing
*  Gamma Knife, Cyberknife

Quick Authorization Form (QAF) - whose responsibilty to get referral ?

Referrals or Prior Notifications

A referral or prior notification is a request by a PCP or a participating specialist for a member to be evaluated and/or treated by a participating specialty physician and/or facility. SHP uses two types of forms and processes:

1. Quick Authorization Form (QAF)

For those services included on the SHP Quick Authorization Form (QAF) (see the Forms Section of this handbook) a referral is NOT required. Primary Care Physicians (PCP’s) can refer a member to a articipating specialist and to many frequently requested services and procedures at free-standing facilities with the Simply Healthcare Plans Quick Authorization Form (QAF) without contacting the health plan for prior authorization.

IMPORTANT NOTE: Communication with the Plan prior to the provision of care is not necessary when using the QAF; however, all inpatient services, outpatient hospital services (including diagnostics), and ASC services do require an authorization (see section below).

Prenatal care referrals are NOT to be made using the QAF.

**The QAF form is not valid for any inpatient or outpatient hospital services or for any consultations or procedures not listed on the form, or for out-of-network providers.

The PCP or specialist ordering the consultation or test is required to fax or mail a copy of the completed QAF to the participating provider or facility that will be providing the service(s), or to give a copy to the member so that it is presented at the time of the service.

Services that Do NOT Require Prior Authorization or QAF:

* Family Planning*

* Participating Office/free standing laboratory tests at labs consistent with CLIA guidelines

* Emergent transportation services

* Urgent or emergent care at participating Urgent Care centers or any Emergency Room

* County Health Departments (CHD), Federally Qualified Health Centers , Rural Health Clinics and federally funded migrant health centers when providing:

* Vaccines

* STD diagnosis/treatment

* Rabies diagnosis/immunization

* Family planning services and related pharmaceuticals

* School health services and urgent services

*NOTE: If the member receives Family Planning Services from a non-network Medicaid provider, the Plan will reimburse the provider at the Medicaid reimbursement rate, unless another payment rate is negotiated.

List of procedure - Authorization required

All of the following procedures and services require Prior Plan Notification and must be provided in a SHP participating facility*:

o Inpatient and Observation Admissions, as noted above

o Admission to any rehabilitation and skilled nursing facility

o All surgical procedures, inpatient or outpatient

o The following have special reporting requirements (refer to Forms Section):

*  Abortions

*  Hysterectomies

*  Sterilization procedures

o Cosmetic or Reconstructive Surgery, including but not limited to:

*  Breast reconstruction or reduction

*  Blepharoplasty

*  Venous procedures

*  Sclerotherapy

o Services and items:

*  Allergy (immunotherapy), exept for those services identified on the QAF

*  Ambulance transportation (non emergent)

*  Amniocentesis

*  Cardiac and pulmonary rehabilitation programs

*  Circumcisions after 12 weeks of age

*  Court-ordered services

*  Chemotherapy

*  Dialysis

*  DME, including apnea monitors and bili-blankets

*  Upper endoscopies at colonoscopies at hospitals

*  Genetic testing

*  Gamma Knife, Cyberknife

*  Hearing aids

*  Home Health Services

*  Hospice care

*  Hyperbaric Oxygen Therapy (HBO)

*  Investigational and experimental procedures and treatments

*  IV Infusions

*  Laboratory services in POS 22 and 24

*  Lithotripsy

*  Mental Health (See Mental Health Section)

*  Nutritional counseling

*  MRI’s, MRA’s

*  Oral Surgery

*  Oxygen therapy and equipment

*  Out-of-Network Services

*  Pain Management and or Pain Injections

*  PET Scans

*  Prenatal care

*  Orthotics and Prosthetics, including Cranial Orthotics

*  Physical, Occupational and Speech Therapy

*  Radiation therapy

*  SPECT scans

*  Transplants and pre and post transplant evaluations

*  Wound Care and wound vacuums

*  Drugs that require pre-authorization

*  Any services or procedures not listed on the Quick Authorization  Form (QAF)

*Unless the service is only available in a non-participating facility. 

Understand Prior Authorization - Full details

Prior Authorizations:

Prior authorization (pre-service requests) allows for the use of quality, cost-efficient covered health care services and helps to ensure that effective transition of care planning is done so that members receive the most appropriate level of care within the most appropriate setting. Prior authorization must be obtained for all services not included on the Quick Authorization Form (QAF) for PCP’s (see section above) that require an authorization.

SHP’s UM Department evaluates requests for services/procedures and makes determinations based on medical necessity, covered benefits and appropriateness based on SHP’s approved utilization criteria (Interqual) and evidence-based, nationally recognized clinical guidelines. Only a Medical Director may issue an adverse determination, with the exception of denials due to benefit issues. 

No provider or any other individual or SHP employee or associate is rewarded for issuing denials of coverage or care. Financial incentives will NOT encourage decisions that would result in underutilization nor are incentives to create barriers to care and services.

Prior Authorization Requests are to be made through the SHP’s UM Pre-Certification Department.

Prior Authorization or Notification Process:

*  Providers are to fax the Referral & Authorization Form (refer to Forms Section) to the SHP’s Utilization Management Pre-Certification Department at Fax number 1-800-283- 2114 or by calling the PreCertification Telephone Queue 1-800- 887-6888, ext 2271.

*  Routine (NOT STAT/URGENT) requests are processed within fourteen (14) calendar days of the Plan receiving the authorization request and having received all supporting clinical information.

STAT/URGENT requests are processed within seventy-two (72) hours of the Plan receiving the request and having received the supporting clinical information.

NOTE: STAT/URGENT Authorizations should be CALLED IN to the SHP Pre-Certification Authorization Telephone Queue and NOT faxed, and the caller should identify the request as “STAT/URGENT”. These requests should always meet the defined medical criteria for such which are:

STAT/URGENT: Any condition where failure to issue an immediate response may result in an IRREVERSIBLE SIGNIFICANT, ADVERSE outcome of health and/or function.

*  Each Referral & Authorization Form received from the provider’s offices will be date and time- stamped, manually or electronically and is reviewed for completeness, eligibility, benefits, PCP and specialist network affiliation

*  The Referral & Authorization Form must be accompanied by supporting clinical information for medical necessity determination

*  An authorization number will be provided, via fax, to the PCP, specialist and other provider(s) that will provide services to the member, when the request is completed and approved

*  All authorization requests and documentation of supporting clinical information will be entered and maintained within the SHP computer system for future reference and claims payment

When faxing a Prior Authorization Request, the SHP Referral & Authorizations Form must be completed. The requesting provider is reminded to include:

*  Member demographic information (i.e. name, sex, DOB, SHP  Member Number)

*  Provider demographic information

* Requesting provider (i.e. name, SHP Provider Number, phone number, fax number, contact person)

* Referred-to specialist/facility (i.e. name, SHP Provider Number, address, phone number, fax number, date of service, and identification if PAR (Plan participating provider/facility) or Non-PAR (not a Plan participating provider/facility)

*  Diagnoses for authorization request, including ICD-9 Code(s)

*  Procedure(s) for authorization request, including CPT/HCPCS Code(s)

*  Number of visits requested, frequency and duration

*  Pertinent medical history and treatment, laboratory and/or radiological data, physical examinations/referrals that support the medical necessity for the requested service(s).

Requests that do not meet medical necessity, based upon approved criteria are reviewed by the Medical Director for a final determination. The Medical Director may conduct a peer-to-peer discussion with the requesting provider, if indicated. 

What is referral in Medical billing - Evaluate and treat

Referral.  

When the referring provider, in writing, transfers complete responsibility of treatment for a specific and/or suspected problem, the receiving provider may not code a consult.  Referrals are “evaluate and treat.”  Outpatient referrals are coded using E&M codes for office visits as the new provider assumes full control of the patient.  Inpatient referrals require the patent be transferred to the new service, at which time the new service begins coding codes from the appropriate Inpatient Hospital Services codes (unless there is a decision for surgery in which case the new attending surgeon would code 99499).  

Medical billing - Blue Medicare HMO referral process

Effective January 1, 2011, Health Options, Inc. (HOI) is instituting a change in the member referral process for all Medicare Advantage (BlueMedicare® HMO and BlueMedicare® Group HMO) members.

 PCP refers a member to a participating specialist. Participating specialist refers a member to another participating specialist.·Notification of a member referral is required when: 

Note: Authorizations are required for all referrals to nonparticipating physicians and providers.

Exempt Covered Services

The following covered services are exempt from the referral requirement: Emergency services Certain specialists including chiropractors, dermatologists and podiatrists Flu shots Laboratory services at a participating Quest laboratory within the member’s service area with a valid prescription Mammograms

The physician or authorized participating specialist is responsible for obtaining any required referral and prior authorization approvals for all services including facility, outpatient, ancillary and professional services. The physician or provider must also verify that the authorization is appropriate, approved and complete before rendering services.

whose responsility is getting authorization

Prior Authorization - BCBS

Who is responsible for getting a prior authorization from Blue Cross and Blue Shield of Florida? 

• If your doctor is a Blue Cross and Blue Shield of Florida participating network provider, he or she is responsible for obtaining a prior authorization and should contact us for you. 

• If your doctor is NOT a Blue Cross and Blue Shield of Florida participating provider or is located outside of Florida, it’s your responsibility to ensure that your doctor gets a prior authorization for you. It’s easy to initiate: Simply have your non-network or out-of-Florida doctor call the number on the back of your ID card. If a prior authorization is not obtained, you may be responsible for the entire cost.  

Important note: In an emergency situation, a prior authorization is NOT required. An emergency is an instance in which the absence of medical attention could jeopardize a person's life, health, or ability to regain maximum function, or could subject a person to severe pain.

What types of medical services require a prior authorization? 

Certain medical services, medical supplies and prescription drugs that may require a prior authorization are listed below. Please refer to your benefit booklet and pharmacy endorsement (if applicable) for prior authorizations that may be required by your medical and/or prescription drug coverage. 

Does prior authorization required in emergency situation

What is prior authorization? 

Prior authorization means that Blue Cross and Blue Shield of Florida must authorize coverage for certain medical services, medical supplies and prescription drugs before they will be covered under your medical or prescription drug plan.  Note: This requirement varies by plan. For details, please refer to your benefit booklet and pharmacy endorsement, if applicable.

 

Is a prior authorization required in an emergency situation? 

No.  If you are taken to an emergency room in an emergency situation, you do not need a prior authorization.  Note: An emergency is an instance in which the absence of medical attention could jeopardize a person's life, health, or ability to regain maximum function, or could subject a person to severe pain.

Authorization and referral

Identifying CPTs require prior authorization

Identifying Services Requiring Prior Authorization

The Alabama Medicaid Agency is responsible for identifying services that require prior approval. Prior authorization is generally limited to specified nonemergency services. The following criteria may further limit or further define the conditions under which a particular service is authorized:

• Benefit limits (number of units or services billable for a recipient during a given amount of time)

• Age (whether the procedure, product, or service is generally provided to a recipient based on age)

• Sex (whether the procedure, product, or service is generally provided to a recipient based on gender)