Page 55 - Aegion PPO SPDs
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Type of Review Timeframe Requirement for Decision and
Notification
Non-urgent Continued Stay/Concurrent 15 calendar days from the receipt of the request
Review Review for ongoing outpatient
treatment
Post-Service Review 30 calendar days from the receipt of the request
If more information is needed to make a decision, the Claims Administrator will tell the requesting Provider
of the specific information needed to finish the review. If the Claims Administrator does not get the specific
information needed by the required timeframe, the Claims Administrator will make a decision based upon
the information it has.
The Claims Administrator will notify You and Your Provider of its decision as required by Federal law. Notice
may be given by one or more of the following methods: verbal, written, and/or electronic.
Important Information
From time to time certain medical management processes (including utilization management, case
management, and disease management) may be waived, enhanced, changed or ended. An alternate
benefit may be offered if in the Plan’s sole discretion, such change furthers the provision of cost effective,
value based and/or quality services.
Certain qualifying Providers may be selected to take part in a program or a provider arrangement that
exempts them from certain procedural or medical management processes that would otherwise apply. Your
claim may also be exempted from medical review if certain conditions apply.
Just because a process, Provider or Claim is exempted from the standards which otherwise would apply,
it does not mean that this will occur in the future, or will do so in the future for any other Provider, claim or
Member. The Plan may stop or change any such exemption with or without advance notice.
You may find out whether a Provider is taking part in certain programs or a provider arrangement by
contacting the Member Services number on the back of Your Identification Card.
The Claims Administrator also may identify certain Providers to review for potential fraud, waste, abuse or
other inappropriate activity if the claims data suggests there may be inappropriate billing practices. If a
Provider is selected under this program, then the Claims Administrator may use one or more clinical
utilization management guidelines in the review of claims submitted by this Provider, even if those
guidelines are not used for all Providers delivering services to this Plan’s Members.
Health Plan Individual Case Management
The Claims Administrator’s individual health plan case management programs (Case Management) helps
coordinate services for Members with health care needs due to serious, complex, and/or chronic health
conditions. The Claims Administrator’s programs coordinate benefits and educate Members who agree to
take part in the Case Management program to help meet their health-related needs.
The Claims Administrator’s Case Management programs are confidential and voluntary and are made
available at no extra cost to You. These programs are provided by, or on behalf of and at the request of,
Your health plan Case Management staff. These Case Management programs are separate from any
Covered Services You are receiving.
If You meet program criteria and agree to take part, the Claims Administrator will help You meet Your
identified health care needs. This is reached through contact and team work with You and/or Your
authorized representative, treating Physician(s), and other Providers.
55
Notification
Non-urgent Continued Stay/Concurrent 15 calendar days from the receipt of the request
Review Review for ongoing outpatient
treatment
Post-Service Review 30 calendar days from the receipt of the request
If more information is needed to make a decision, the Claims Administrator will tell the requesting Provider
of the specific information needed to finish the review. If the Claims Administrator does not get the specific
information needed by the required timeframe, the Claims Administrator will make a decision based upon
the information it has.
The Claims Administrator will notify You and Your Provider of its decision as required by Federal law. Notice
may be given by one or more of the following methods: verbal, written, and/or electronic.
Important Information
From time to time certain medical management processes (including utilization management, case
management, and disease management) may be waived, enhanced, changed or ended. An alternate
benefit may be offered if in the Plan’s sole discretion, such change furthers the provision of cost effective,
value based and/or quality services.
Certain qualifying Providers may be selected to take part in a program or a provider arrangement that
exempts them from certain procedural or medical management processes that would otherwise apply. Your
claim may also be exempted from medical review if certain conditions apply.
Just because a process, Provider or Claim is exempted from the standards which otherwise would apply,
it does not mean that this will occur in the future, or will do so in the future for any other Provider, claim or
Member. The Plan may stop or change any such exemption with or without advance notice.
You may find out whether a Provider is taking part in certain programs or a provider arrangement by
contacting the Member Services number on the back of Your Identification Card.
The Claims Administrator also may identify certain Providers to review for potential fraud, waste, abuse or
other inappropriate activity if the claims data suggests there may be inappropriate billing practices. If a
Provider is selected under this program, then the Claims Administrator may use one or more clinical
utilization management guidelines in the review of claims submitted by this Provider, even if those
guidelines are not used for all Providers delivering services to this Plan’s Members.
Health Plan Individual Case Management
The Claims Administrator’s individual health plan case management programs (Case Management) helps
coordinate services for Members with health care needs due to serious, complex, and/or chronic health
conditions. The Claims Administrator’s programs coordinate benefits and educate Members who agree to
take part in the Case Management program to help meet their health-related needs.
The Claims Administrator’s Case Management programs are confidential and voluntary and are made
available at no extra cost to You. These programs are provided by, or on behalf of and at the request of,
Your health plan Case Management staff. These Case Management programs are separate from any
Covered Services You are receiving.
If You meet program criteria and agree to take part, the Claims Administrator will help You meet Your
identified health care needs. This is reached through contact and team work with You and/or Your
authorized representative, treating Physician(s), and other Providers.
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