Please send all claims to:

Medical Network One, P.C.

Attention: CLAIMS
4986 Adams Rd. Suite D
Rochester, MI, 48306-1416

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For most updated information please download Pre-Certification file.  This file in Microsoft Word format.

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Immunizations are fee for service.

These guidelines are recommended by BCN for healthy adults and children. 

Adult Immunizations

Service	For	Age 18-39	Age 40-64	Age 65+
Influenza	Influenza (flu)	Annually for certain chronic conditions. Discuss with your physician.	Annually starting at age 50	Annually
Td	Tetanus	Every 10 years	Every 10 years	Every 10 years
Pneumococcal	Pneumococcal Disease (meningitis and pneumonia)	Persons at high risk for pneumococcal disease. Discuss with your physician.		At age 65+

Recommended Childhood Immunization Schedule
United States, January - December 2000
Vaccines¹ are listed under routinely recommended ages. Light gray bars indicate range of recommended ages for immunization. Any dose not given at the recommended age should be given as a “catch-up” immunization at any subsequent visit when indicated and feasible. Dark gray bars indicate vaccines to be given if previously recommended doses were missed or given earlier than the recommended minimum age.  You can download The Recommended Childhood Immunization Schedule from Blue Care Network in PDF format.  To open that file you will need Acrobat Reader which is available free.

Childhood Immunization Schedule

Age           Vaccine

Birth

1 mo

2 mos

4 mos

6 mos

12 mos

15 mos

18 mos

24 mos

4-6 yrs

11-12 yrs

14-16 yrs

Hepatitis B2

Hep B

Hep B

Hep B

Hep B

Diptheria, Tetanus, Pertussis3

DTaP

DTaP

DTaP

DTaP3

DTaP

Td

H. influenzae type b4

Hib

Hib

Hib

Hib

Polio5

IPV

IPV

IPV5

IPV5

Measles, Mumps, Rubella6

MMR

MMR6

MMR6

Varicella7

Var

Var7

Hepatitis A8

Hep A8- in selected areas

 

 

 

 

 

 

 

 

 

 

 

 

 

Approved by the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP).

On October 22, 1999, the Advisory Committee on Immunization Practices (ACIP) recommended that Rotashield® (RRV-TV), the only U.S.-licensed rotavirus vaccine, no longer be used in the United States (MMWR, Volume 48, Number 43, Nov. 5, 1999). Parents should be reassured that their children who received rotavirus vaccine before July are not at increased risk for intussusception now.

¹ This schedule indicates the recommended ages for routine administration of currently licensed childhood vaccines as of 11/1/99. Additional vaccines may be licensed and recommended during the year. Licensed combination vaccines may be used whenever any components of the combination are indicated and its other components are not contraindicated. Providers should consult the manufacturers’ package inserts for detailed recommendations.

² Infants bom to HBsAg-negative mothers should receive the 1st dose of hepatitis B (Hep B) vaccine by age 2 months. The 2nd dose should be at least one month after the 1st dose. The 3rd dose should be administered at least 4 months after the 1st dose and at least 2 months after the 2nd dose, but not before 6 months of age for infants.

Infants born to HBsAg-positive mothers should receive hepatitis B vaccine and 0.5 mL hepatitis B immune globulin (HBIG) within 12 hours of birth at separate sites. The 2nd dose is recommended at 1-2 months of age and the 3rd dose at 6 months of age.

Infants born to mothers whose HBsAg status is unknown should receive hepatitis B vaccine within 12 hours of birth. Maternal blood should be drawn at the time of delivery to determine the mother’s HBsAg status; if the HBsAg test is positive, the infant should receive HBIG as soon as possible (no later than 1 week of age).

All children and adolescents (through 18 years of age) who have not been immunized against hepatitis B may begin the series during any visit. Special efforts should be made to immunize children who were born in or whose parents were born in areas of the world with moderate or high endemicity of hepatitis B virus infection.

³ The 4th dose of DTaP (diphtheria and tetanus toxoids and acellular pertussis vaccine) may be administered as early as 12 months of age, provided 6 months have elapsed since the 3rd dose and the child is unlikely to return at age 15-18 months. Td (tetanus and diphtheria toxoids) is recommended at 11-12 years of age if at least 5 years have elapsed since the last dose of DTP, DTaP or DT. Subsequent routine Td boosters are recommended every 10 years.

⁴ Three Haemophilus influenzae type b (Hib) conjugate vaccines are licensed for infant use. If PRP-OMP (PedvaxHIB ® or ComVax ® [Merck]) is administered at 2 and 4 months of age, a dose at 6 months is not required. Because clinical studies in infants have demonstrated that using some combination products may induce a lower immune response to the Hib vaccine component, DTaP/Hib combination products should not be used for primary immunization in infants at 2, 4 or 6 months of age, unless FDA-approved for these ages.

⁵ To eliminate the risk of vaccine-associated paralytic polio (VAPP), an all-lPV schedule is now recommended for routine childhood polio vaccination in the United States. All children should receive four doses of IPV at 2 months, 4 months, 6-18 months, and 4-6 years. OPV (if available) may be used only for the following special circumstances:

1. Mass vaccination campaigns to control outbreaks of paralytic polio.
   
2. Unvaccinated children who will be traveling in 4 weeks to areas where polio is endemic or epidemic.
   
3. Children of parents who do not accept the recommended number of vaccine injections. These children may receive OPV only for the third or fourth dose or both; in this situation, health-care providers should administer OPV only after discussing the risk for VAPP with parents or caregivers.
   
4. During the transition to an all-lPV schedule, recommendations for the use of remaining OPV supplies in physicians’ offfices and clinics have been issued by the American Academy of Pediatrics (see Pediatrics, December 1999).

⁶ The 2nd dose of measles, mumps, and rubella (MMR) vaccine is recommended routinely at 4-6 years of age but may be administered during any visit, provided at least 4 weeks have elapsed since receipt of the 1st dose and that both doses are administered beginning at or after 12 months of age. Those who have not previously received the second dose should complete the schedule by the 11-12 year old visit.

⁷ Varicella (Var) vaccine is recommended at any visit on or after the first birthday for susceptible children, i.e. those who lack a reliable history of chicken pox (as judged by a health care provider) and who have not been immunized. Susceptible persons 13 years of age or older should receive 2 doses, given at least 4 weeks apart.

⁸ Hepatitis A (Hep A) is shaded to indicate its recommended use in selected states and/or regions; consult your local public health authority. (Also see MMWR Oct. 01, 1999/48(RR12); 1-37).

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Dual Choice program for women only

OB-GYN may perform these services without a referral from the primary care physician

Breast physical examination Diagnosis and treatment for obstetric diagnoses Diagnosis and treatment of cystitis and other minor gynecological infections Diagnosis and treatment of female related conditions Female-related ultrasounds (pelvic area to rule out fibroids) Fetal nonstress test Gynecological examinations and no surgical treatment of gynecologic disorders Infertility studies performed in the Dual Choice office Laboratory and pathology services related to gynecological problems Mammograms1 Maternity ultrasound2 Obstetrics procedures, including diagnostic lab3 and radiology Pap smears1 Rhogam injections Pregnancy termination

OB-GYN may perform or issue a referral for these services

Laboratory and radiology services related to routine obstetric care Maternity ultrasound2 Mammograms1 Amniocentesis Laboratory services related t gynecologic problems3 Pregnancy termination not performed in the Dual Choice OB-GYN office Fetal nonstress test Rhogan injections Hospital admissions for delivery/obstetric care Pelvic ultrasounds

OB-GYN must get a authorization form primary care physician for these services

Infertility studies not performed in the Dual Choice office Hospital admissions for conditions other than delivery Outpatient surgical procedures which fall in the "Female Genital" CPT-4 procedure code range related to gynecological problems Radiology or diagnosis procedures not related to obstetric services (excluding pelvis ultrasounds) Referral to other specialists Management of medical problems during pregnancy (e.g. hypertensions and diabetes) either in hospital or by referral Suspected or confirmed malignancies In-office surgical procedures

1In accordance with BCN guidelines for adult heal maintenance examination. 2In accordance with BCN/BCBSM policy. Note: Uncomplicated pregnancy ultrasound are not covered. 3Must be send to BCN for approved laboratories.

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Check your specialist directory.  If not please contact Medical Network One.  In the near future this list will be available for downloading.

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Please select:

CAT SCANS    MRI    ARTERIAL/VENOUS DOPPLER    EMG    EEG    SLEEP STUDY

CAT SCANS

Clarkston CT P93235
6770 Dixie Highway, Suite 100
Clarkston
(248) 922-9353

BASHA Diagnostics P51414
4045 W. 13 Mile
Royal Oak, 48076
(248) 435-8066

Contemporary Imaging Assoc. P 43752
1990 Haggerty Rd., Suite 101
Livonia, 48154
(734) 462-3232

Southgate Radiology P43980
15300 Trenton Rd.
Southgate, 48195
(734) 281-6600

MIND P50323
28595 Orchard Lake Rd., Suite 200
Farmington Hills
(248) 553-8770, (248) 553-0010

CT Scanning Center P74963
4000 Highland Rd., Suite 102
Waterford, 48328
(248) 738-0801

Harper Metro Radiology P42851
36561 Harper, Suite F
Clinton Twsp.
(810) 791-0620

Diagnostic Imaging P43797
28800 Ryan Rd., Suite 250
Warren, 48092
(810) 778-7870

Rochester Diagnostics P70404
543 N. Main
Rochester, 48307
(248) 656-3105

Fairview Radiology P71541
5245 Schaefer Rd.
Dearborn, 48126
(313) 581-3000

Associated Radiology P 43327
1383 Woodward Ave, Suite 204
Bloomfield Hills, 48302
(248) 338-0491

Universal Imaging P87841
3100 Cross Creek Parkway
Auburn Hills, 48326
Tel 248.370.8980
Fax 248.370.8970

Universal Imaging P87841
8560 Silvery Lane, Suite A-100
Dearborn Heights, MI 48127
Tel 313.359.1653
Fax 313.359.1657


Universal Imaging P87841
Heritage Medical Center
1159 E. Michigan Ave.
Ypsilanti, MI 48198
Tel 734.528.0657
Fax 734.528.0659

Eastland Diagnostics
25710 Kelly Road
Roseville, 48066
(810) 779-4610

Grosse Pointe Physician X-ray Ctr
21003 Mack
Grosse Pointe, 48236
(313) 881-0411

MRI

Wayne-Macomb MRI P42884
18245 Ten Mile Rd.
Roseville, 48066
(810) 775-6400

MRI Center Southfield P43272
29877 Telegraph, Suite 11
Southfield, 48034
(248) 354-5511

Wide Open MRI P101196
6545 W. Central Suite 104
Toledo, OH 43617
(888) 381-6736
(419) 841-0505

BioMagnetic P43352
30781 Stephenson Hwy.
Madison Heights, 48071
(248) 585-5115, (248) 585-5116

MI Resonance Imaging P64943
355 Barclay Circle
Rochester Hills, 48307
(248) 299-8000

Universal Imaging
4600 Investment Dr. Suite 160
Troy, MI 48098
Tel 248.312.0294
Fax 248.312.0091

Wayne Macomb MRI P82732
19 & Schoenherr
Sterling Heights .
(810) 775-6400

TRI Hospital P78249
1221 Pine Grove
Port Huron, 48060
(810) 987-2428

Harper Metro P42851
36561 Harper, Suite F
Clinton Twsp
(810) 791-0620

MRI Center Oakland P49094
27379 Dequindre
Madison Heights., 48071
(248) 398-4488

MIND P50323
28595 Orchard lake Rd., Suite 200
Farmington Hills
(248) 553-0010

ARTERIAL/VENOUS DOPPLER

Grosse Pointe Radiology
21003 Mack
Grosse Pointe Woods, MI
(313) 881-0411

Rochester Diagnostics P70404
543 N. Main
Rochester, 48307
(248) 656-3105
Venous Studies only

Downriver Cardiology Consultant
2205 Riverside Drive
Trenton, 48183
(734) 675-2220

BASHA Diagnostics P51414
4045 W. 13 Mile
Royal Oak, 48076
(248) 288-1600

Universal Imaging P87841
3100 Cross Creek Parkway
Auburn Hills, 48326
(248) 370-8980
(248) 478-5234 Ypsilanti
(313) 359-1653 Dearborn Heights

EMG

Dr. Brazil
Downriver Neurology
(734) 479-4574

Dr. Tashjian
Bloomfield (248) 332-0296
Rochester (248) 656-2844

Dr. Tolia
Bloomfield Hills
(248) 334-0115

Dr. Glass
Bloomfield
(248) 338-8400

Dr. Kaner
19 Mile & Hayes
Sterling Heights
(810) 286-2770

EEG

Dr. Brazil
Downriver Neurology
(734) 479-4574

Dr. Kaner
19 Mile & Hayes
(810) 286-2770

MIND
28595 Orchard Lake Rd.,
Farmington Hills
(248) 553-8770
(248) 553-0010

SLEEP STUDY FACILITIES

Sleep and Respiratory Asso. of MI
Harvey Organek MD P40762
28200 Franklin Rd.
Southfield, 48034
(248) 350-2722

Pulmonary & Critical Care Med. Cons.
Bradley Rowens MD P73241
Robert Reagle MD
Mark Dunn MD
Daniel Maxwell MD
31410 Northwestern Hwy., Suite G
Farmington Hills, 48334
(248) 538-1350

Sleep Disorder Institute
Rahul Sangal MD P40339
44199 Dequindre Rd., Suite 311
Troy, 48098
(248) 879-0707

Michigan Downriver Neurology
Michael Brazil DO P100609
14600 King Rd., Suite D
Riverview, 48192
(734) 479-4574

Michigan Sleep Consultants
Thomas Gianacarlo DO P76965
14061 Thirteen Mile Rd, Suite 2
Warren, 48093
(810) 415-5578

MI Center for Sleep Disorders
Dr. Haranath Policherla P90311
26635 Woodward
Huntington Woods 48070
(248) 541-7706

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