Page 48 - Aegion PPO SPDs
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HEALTH CARE MANAGEMENT – PRECERTIFICATION
Your Plan includes the process of Utilization Review to decide when services are Medically Necessary or
Experimental/Investigative as those terms are defined in this Benefit Booklet. Utilization Review aids the
delivery of cost-effective health care by reviewing the use of treatments and, when proper, level of care
and/or the setting or place of service that they are performed. A service must be Medically Necessary to
be a Covered Service. When level of care, setting or place of service is part of the review, services that
can be safely given to You in a lower level of care or lower cost setting / place of care, will not be Medically
Necessary if they are given in a higher level of care, or higher cost setting / place of care.
Certain Services must be reviewed to determine Medical Necessity in order for You to get benefits.
Utilization Review criteria will be based on many sources including medical policy and clinical guidelines.
The Plan may decide that a treatment that was asked for is not Medically Necessary if a clinically equivalent
treatment that is more cost effective is available and appropriate.
If You have any questions regarding the information contained in this section, You may call the Member
Services telephone number on Your Identification Card or visit www.anthem.com.
Coverage for or payment of the service or treatment reviewed is not guaranteed even if the Plan
decides Your services are Medically Necessary. For benefits to be covered, on the date You get
service:
1. You must be eligible for benefits;
2. Fees must be paid for the time period that services are given;
3. The service or supply must be a Covered Service under Your Plan;
4. The service cannot be subject to an Exclusion under Your Plan; and
5. You must not have exceeded any applicable limits under Your Plan.
Types of Reviews:
Pre-service Review – A review of a service, treatment or admission for a benefit coverage
determination which is done before the service or treatment begins or admission date.
Precertification – A required Pre-service Review for a benefit coverage determination for a service or
treatment. Certain services require Precertification in order for You to get benefits. The benefit
coverage review will include a review to decide whether the service meets the definition of Medical
Necessity or is Experimental / Investigative as those terms are defined in this Benefit Booklet.
For admissions following Emergency Care, You, Your authorized representative or Doctor must tell the
Claims Administrator no later than 2 business days after admission or as soon as possible within a
reasonable period of time. For childbirth admissions, Precertification is not needed unless there is a
problem and/or the mother and baby are not sent home at the same time. Precertification is not required
for the first 48 hours for a vaginal delivery or 96 hours for a cesarean section. Admissions longer than
48/96 hours require precertification.
Continued Stay/Concurrent Review - A Utilization Review of a service, treatment or admission for a
benefit coverage determination which must be done during an ongoing stay in a Facility or course of
treatment.
Both Pre-Service and Continued Stay/Concurrent Reviews may be considered urgent when, in the view of
the treating Provider or any Doctor with knowledge of Your medical condition, without such care or
treatment, Your life or health or Your ability to regain maximum function could be seriously threatened or
You could be subjected to severe pain that cannot be adequately managed without such care or treatment.
Urgent reviews are conducted under a shorter timeframe than standard reviews.
48
Your Plan includes the process of Utilization Review to decide when services are Medically Necessary or
Experimental/Investigative as those terms are defined in this Benefit Booklet. Utilization Review aids the
delivery of cost-effective health care by reviewing the use of treatments and, when proper, level of care
and/or the setting or place of service that they are performed. A service must be Medically Necessary to
be a Covered Service. When level of care, setting or place of service is part of the review, services that
can be safely given to You in a lower level of care or lower cost setting / place of care, will not be Medically
Necessary if they are given in a higher level of care, or higher cost setting / place of care.
Certain Services must be reviewed to determine Medical Necessity in order for You to get benefits.
Utilization Review criteria will be based on many sources including medical policy and clinical guidelines.
The Plan may decide that a treatment that was asked for is not Medically Necessary if a clinically equivalent
treatment that is more cost effective is available and appropriate.
If You have any questions regarding the information contained in this section, You may call the Member
Services telephone number on Your Identification Card or visit www.anthem.com.
Coverage for or payment of the service or treatment reviewed is not guaranteed even if the Plan
decides Your services are Medically Necessary. For benefits to be covered, on the date You get
service:
1. You must be eligible for benefits;
2. Fees must be paid for the time period that services are given;
3. The service or supply must be a Covered Service under Your Plan;
4. The service cannot be subject to an Exclusion under Your Plan; and
5. You must not have exceeded any applicable limits under Your Plan.
Types of Reviews:
Pre-service Review – A review of a service, treatment or admission for a benefit coverage
determination which is done before the service or treatment begins or admission date.
Precertification – A required Pre-service Review for a benefit coverage determination for a service or
treatment. Certain services require Precertification in order for You to get benefits. The benefit
coverage review will include a review to decide whether the service meets the definition of Medical
Necessity or is Experimental / Investigative as those terms are defined in this Benefit Booklet.
For admissions following Emergency Care, You, Your authorized representative or Doctor must tell the
Claims Administrator no later than 2 business days after admission or as soon as possible within a
reasonable period of time. For childbirth admissions, Precertification is not needed unless there is a
problem and/or the mother and baby are not sent home at the same time. Precertification is not required
for the first 48 hours for a vaginal delivery or 96 hours for a cesarean section. Admissions longer than
48/96 hours require precertification.
Continued Stay/Concurrent Review - A Utilization Review of a service, treatment or admission for a
benefit coverage determination which must be done during an ongoing stay in a Facility or course of
treatment.
Both Pre-Service and Continued Stay/Concurrent Reviews may be considered urgent when, in the view of
the treating Provider or any Doctor with knowledge of Your medical condition, without such care or
treatment, Your life or health or Your ability to regain maximum function could be seriously threatened or
You could be subjected to severe pain that cannot be adequately managed without such care or treatment.
Urgent reviews are conducted under a shorter timeframe than standard reviews.
48
