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1. What is Pre-Certification
or Pre-Notification?
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2.
What procedures must be
Pre-Certified?
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3.
When must procedures be
Pre-Certified?
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4.
What is the number to
call to Pre-Certify a procedure?
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5.
How does Pre-Certification
affect what the Plan pays?
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6.
How does
Pre-Certification benefit the patient?
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7.
Does a Pre-Certification
of procedure guarantee coverage?
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8.
Will the
insurance company determine what procedures and treatment I will receive?
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What
is Pre-Certification or Pre-Notification?
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Medical Review and Continued Stay Review are
the processes used to review expected medical treatments. It is each Insured's responsibility to
notify the Medical Review Organization prior to specified treatment and to
notify the Medical Review Organization for each emergency hospital
confinement within 48 hours. Please
notify your doctor and tell him/her to call this toll free number also listed
on your Group Insurance Identification Card.
There may be a permanent reduction in your benefits if Pre-Treatment
Notification and approval procedures are not followed. See also Transplants, below and Extended
Care Facility, below.
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What procedures must be Pre-Certified?
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A) All Scans
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B) Pain Clinic Therapy
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C) Ultrasound in
Pregnancy
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D) Invasive procedures
& tests
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E)
Allergy Testing
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F)
Physical Therapy
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G)
Speech Therapy
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H)
Occupational Therapy
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Dental
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If the estimated
cost of a recommended treatment plan exceeds $200, the Covered Person must
submit the treatment plan to the Company for the Company's review before
treatment begins. After treatment begins,
an additional treatment plan review will be required if: (1) there is a
change in the original treatment plan; or (2) it appears that the charges
will exceed the amount of the original treatment plan. Pre-Determination of
Benefits will be used to determine Dental Expense Benefits. Pre-Determination
of Benefits will not extend Dental Expense Benefits beyond those otherwise
payable under this Policy. Pre-Determination
of Benefits is not necessary for emergency treatment.
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When must procedures be Pre-Certified?
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PRE-CERTIFICATION
and PRE-TREATMENT NOTIFICATION IS REQUIRED before all non-emergency hospital
admissions and surgery and within 48 hours after emergency admissions and
when having any of the above indicated
tests or procedures.
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What is the number to call to Pre-Certify a procedure?
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1-800-238-1602
for Pre-Treatment Notification
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1-800-354-4768 for Prior Approval on All FDA
approved, Non-experimental Transplant Benefits
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1-800-238-1602 for Prior
Approval on Extended Care Facility Benefits
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How does Pre-Certification affect what the Plan pays?
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The Pre-Certification results may determine
how much the Plan will pay and what expenses and treatment are eligible.
If you fail to seek Pre-Certification
approval on a timely basis, as required by the Plan, the Plan benefits will
be limited to the amount of expenses that would have been eligible had
medical necessary treatment been performed at the nearest qualified
participating In-Network Provider. In
addition, this Plan will reduce its benefit payment by an additional 20% with
a minimum reduction of $250. This
reduction will not apply to deductibles, copays, coinsurance or any other
out-of-pocket Plan benefits.
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How does Pre-Certification benefit the patient?
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The Plan allows
patients the access to Registered Nurses at time of Pre-Certification. If a patient has a question that a
Registered Nurse could help answer or help a patient understand what their
doctor has recommended as a course of treatment.
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Does a Pre-Certification of procedure guarantee
coverage?
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Pre-Treatment Notification
and/or Pre-Certification is not a representation of any kind, it is not an endorsement
of any medical treatment, and is not a guarantee of coverage or payment. The Pre-Treatment information is provided for
the use of the Plan only.
Eligibility is required
and all provisions of the Policy apply. If does not provide for payment of any benefits
or eligibility of coverage if benefits are not otherwise due.
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Will the insurance company determine what procedures and
treatment I will receive?
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Of course, the final
decision on the treatment you receive will always rest with you and your
doctor.
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