Mandatory Pre-Authorization Review
Unnecessary tests, surgery and treatment overuse occur regularly within the health care system and can increase costs without improving health. By evaluating the medical necessity of an inpatient confinement for proposed treatment and determining the appropriate length of stay, it is possible to lower medical costs. This ensures that insureds are in the hospital only when they need to be.
For non-emergency confinement, a insured must notify his or her doctor of participation in this program and request that the doctor call our toll-free number to obtain authorization for a predefined number of hospital days prior to any admission. The insured can also initiate the review process by calling the toll-free number.
In case of emergency, the doctor, insured or family member must call for a review within 48 hours (72 hours on holidays and weekends) after admission.
Prenatal Program
Our prenatal program is designed to assist the insured in having a healthy full-term baby and avoiding a problem pregnancy. Besides providing prenatal education and a health screening to determine risk, we provide high-risk mothers individualized attention and case management services to encourage a healthy delivery.
Medical Case Management
A terrible accident or devastating illness can turn a person's life upside down. Our case management program is available to deal with medical catastrophes. It's in place to help insured employees and dependents at times when they need special assistance. Something as simple as teaching a spinal cord injury victim, who is paralyzed, how to care for his or her skin, will avoid unnecessary complications. When needed, a rehabilitation specialist will assist the patient in receiving the best care in the most appropriate facility to ensure that available benefits are used efficiently.
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