| SERIAL NUMBER | Procedure | 1st Qtr | Per Qtr (for next 3 Qtrs) | Requirements while submitting for follow-up Preauth | Requirements while submitting for follow-up Claims |
|---|---|---|---|---|---|
| 85 | FP0085 : Sickle Cell Anemia | 2,000 | 1,000 | Previous Discharge Summary | (Clinical Evaluation, Hb,CBC-Mandatory) |
| 113 | FP0113 : Thalassemia Major requiring Chelation | 2,500 | 2,500 | Previous Discharge Summary | (Clinical Evaluation, Hb%, Serum Iron Values, Serum Ferritin-Mandatory) |
