Page 54 - Aegion PPO SPDs
P. 54
Provider Network Responsibility to Comments
Status Get Precertification
and or setting is found to not be Medically
Necessary.
Blue Card Provider Member Member must get Precertification when
outside the service areas (Except for Inpatient required. (Call Member Services.)
of the states listed in the Admissions) Member may be financially responsible for
column above and charges/costs related to the service and/or
BlueCard Providers in setting in whole or in part if the service
other states not listed, and or setting is found to not be Medically
Necessary.
Blue Card Providers must obtain
precertification for all Inpatient
Admissions.
NOTE: For an Emergency Care admission, precertification is not required. However, 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.
The Claims Administrator will utilize its clinical coverage guidelines, such as medical policy, clinical
guidelines, and other applicable policies and procedures to help make Medical Necessity decisions.
Medical policies and clinical guidelines reflect the standards of practice and medical interventions identified
as proper medical practice. The Claims Administrator reserves the right to review and update these clinical
coverage guidelines from time to time.
You are entitled to ask for and get, free of charge, reasonable access to any records concerning Your
request. To ask for this information, call the Precertification phone number on the back of Your Identification
Card.
If You are not satisfied with the Plan’s decision under this section of Your benefits, please refer to the “Your
Right To Appeal” section to see what rights may be available to You.
Decision and Notice Requirements
The Claims Administrator will review requests for benefits according to the timeframes listed below. The
timeframes and requirements listed are based on Federal laws. You may call the phone number on the
back of Your Identification Card for more details.
Type of Review Timeframe Requirement for Decision and
Notification
Urgent Pre-service Review 72 hours from the receipt of request
Non-Urgent Pre-service Review 15 calendar days from the receipt of the request
Urgent Continued Stay/Concurrent Review 24 hours from the receipt of the request
when request is received more than 24
hours before the end of the previous
authorization
Urgent Continued Stay/Concurrent Review 72 hours from the receipt of the request
Review when request is received less than
24 hours before the end of the previous
authorization or no previous authorization
exists
54
Status Get Precertification
and or setting is found to not be Medically
Necessary.
Blue Card Provider Member Member must get Precertification when
outside the service areas (Except for Inpatient required. (Call Member Services.)
of the states listed in the Admissions) Member may be financially responsible for
column above and charges/costs related to the service and/or
BlueCard Providers in setting in whole or in part if the service
other states not listed, and or setting is found to not be Medically
Necessary.
Blue Card Providers must obtain
precertification for all Inpatient
Admissions.
NOTE: For an Emergency Care admission, precertification is not required. However, 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.
The Claims Administrator will utilize its clinical coverage guidelines, such as medical policy, clinical
guidelines, and other applicable policies and procedures to help make Medical Necessity decisions.
Medical policies and clinical guidelines reflect the standards of practice and medical interventions identified
as proper medical practice. The Claims Administrator reserves the right to review and update these clinical
coverage guidelines from time to time.
You are entitled to ask for and get, free of charge, reasonable access to any records concerning Your
request. To ask for this information, call the Precertification phone number on the back of Your Identification
Card.
If You are not satisfied with the Plan’s decision under this section of Your benefits, please refer to the “Your
Right To Appeal” section to see what rights may be available to You.
Decision and Notice Requirements
The Claims Administrator will review requests for benefits according to the timeframes listed below. The
timeframes and requirements listed are based on Federal laws. You may call the phone number on the
back of Your Identification Card for more details.
Type of Review Timeframe Requirement for Decision and
Notification
Urgent Pre-service Review 72 hours from the receipt of request
Non-Urgent Pre-service Review 15 calendar days from the receipt of the request
Urgent Continued Stay/Concurrent Review 24 hours from the receipt of the request
when request is received more than 24
hours before the end of the previous
authorization
Urgent Continued Stay/Concurrent Review 72 hours from the receipt of the request
Review when request is received less than
24 hours before the end of the previous
authorization or no previous authorization
exists
54
