Page 15 - QCS.19 SPD - HSA
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Hospital Inpatient Stay
            For out-of-network benefits, you must obtain prior authorization 5 business days before a scheduled admission, or
            as soon as is reasonably possible for a non-scheduled admission, including emergency admissions.

            Lab, X-Ray and Diagnostic - Outpatient
            For out-of-network benefits, you must obtain prior authorization 5 business days before scheduled services are
            received; or for non-scheduled services, within one business day or as soon as is reasonably possible.

            Major Diagnostic and Imaging
            For out-of-network benefits, you must obtain prior authorization 5 business days before scheduled services are
            received; or for non-scheduled services, within one business day or as soon as is reasonably possible.
            Maternity Services
            For out-of-network benefits, you must obtain prior authorization as soon as reasonably possible if the inpatient
            stay for the mother and/or the newborn will be more than 48 hours following a normal vaginal delivery or more
            than 96 hours following a caesarean section delivery.

            Mental Health Care Services and Substance-Related and Addictive Disorders Services
            For out-of-network benefits for inpatient services (including services at a Residential Treatment facility), you must
            obtain prior authorization before a scheduled admission, or as soon as is reasonably possible for a non-scheduled
            admission, including emergency admissions.
            For out-of-network benefits for outpatient services, you must obtain prior authorization before receiving the
            following services:  partial hospitalization/day treatment, intensive outpatient treatment programs; electro-
            convulsive treatment; psychological testing; or extended outpatient treatment visits beyond 45 - 50 minutes in
            duration with or without medication management or medication assisted treatment programs for substance-
            related and addictive disorders; Intensive Behavioral Therapy, including Applied Behavioral Analysis (ABA).

            Outpatient Surgery
            For out-of-network benefits for outpatient surgery, you must obtain prior authorization 5 business days before
            receiving scheduled services; or for non-scheduled services, within one business day or as soon as is reasonably
            possible.
            Pharmaceutical Products
            For out-of-network Benefits you must obtain prior authorization five business days before certain Pharmaceutical
            Products are received, or for non-scheduled services, within one business day or as soon as is reasonably
            possible.

            Prosthetic Devices
            For out-of-network benefits, you must obtain prior authorization before obtaining prosthetic devices that exceed
            $1,000 in cost per device.

            Reconstructive Procedures, including breast reconstruction surgery following mastectomy
            For out-of-network benefits for outpatient surgery, you must obtain prior authorization 5 business days before a
            scheduled reconstructive surgery is performed; or for non-scheduled reconstructive surgery, within one business
            day or as soon as is reasonably possible.
            Rehabilitation and Inpatient Rehabilitation Facility Services/Skilled Nursing Facility
            For out-of-network benefits for inpatient rehabilitation or confinement in an extended care facility, you must obtain
            prior authorization 5 business days before a scheduled admission; or as soon as is reasonably possible prior to a
            non-scheduled admission.

            Therapeutic Treatments
            For out-of-network benefits, you must obtain prior authorization for dialysis, intravenous chemotherapy, other
            intravenous infusion therapy, radiation therapy, or MR-guided focused ultrasound 5 business days before
            scheduled services are received; or for non-scheduled services, within one business day or as soon as is
            reasonably possible.
            Transplants
            For network and out-of-network benefits, you must obtain prior authorization as soon as the possibility of a
            transplant arises and before the time a pre-transplant evaluation is performed at a transplant center.
            At the time you seek to obtain prior authorization for a transplant, we will discuss with you the health care and
            financial advantages of using the services of a designated facility.






            Page 10                                                                    Section 4 - Schedule of Benefits
                                                                                                     HSA - 2017
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