Summary

This section describes the various medical review programs used by the Carpenters Health and Security Plan. These programs do not apply to Medicare-eligible retirees or to participants that participate in the plan's Kaiser option. For Kaiser's preauthorization program, please refer to the Kaiser plan booklet.

Topics Discussed in This Section

• Introduction
• Preauthorization
• Utilization Management
• Case Management

Previous Policy

Introduction

The plan has preauthorization and case management programs provided by the PPO network. These programs are not designed to be the practice of medicine or to be a substitute for the medical judgment of the attending physician or other health care providers. In order to maximize plan reimbursements, please read the following provisions carefully.

Previous Policy

Preauthorization

The plan requires preauthorization for certain medical services. Preauthorization is the process of determining in advance whether a procedure, treatment or service is medically necessary. Preauthorization also helps confirm whether the plan will cover certain tests and procedures before the test or procedure is performed or before the patient is admitted into a hospital. The preauthorization process confirms the procedure meets medical necessity criteria.

Preauthorization by Network Providers

If you use a network provider, preauthorization is done by the provider. If the network provider does not obtain the required preauthorization, benefits are not provided by the plan if the services are rendered. In addition, the participant and the patient are exempt from any financial liability for the applicable service(s), unless they agreed otherwise with the provider.

Preauthorization by Non-Network Providers

If a non-network provider is used, then you, the patient, or the provider must request preauthorization. If preauthorization is not obtained and it is determined that the service was not medically necessary, no benefits will be provided and you will be financially responsible for 100 percent of the related services. If preauthorization is not obtained, but it is subsequently determined that the service was medically necessary and covered, then the following penalty applies:

• $50 is deducted from the room and board maximum allowable fee for each day of inpatient care, up to a maximum of $250. The penalty does not apply if the claim is for urgent care, where the delay in treatment could: seriously jeopardize the life or health of the patient or the ability of the patient to regain maximum function; or subject the patient to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

To preauthorize non-network provider services, your provider must call the provider number on the back of the ID card.

Services Requiring Preauthorization

The following is a sample list of common items that require preauthorization: All inpatient admissions, genetic testing, organ transplants, reconstructive and spinal surgeries, dialysis, cochlear implants, bariatric surgery, proton beam therapy, non-emergency medical transportation, and infused or injectable drugs.

For questions regarding whether a service or supply requires preauthorization, have your provider call the provider number on the back of your ID card.

Previous Policy

Utilization Management

Utilization management begins once an admission or procedure is precertified. Utilization management includes concurrent review of the hospitalization or services requested by the attending physician; on-going certification of services; and planning for discharge from a medical care facility and completion of medical treatment.

A case manager will monitor the patient's stay or use of other medical services and coordinate the scheduled release or an extension of the stay or extension or cessation of the use of other medical services with the patient, attending physician, and/or hospital.

If the attending physician feels that it is medically necessary for a patient to receive additional services or to extend an admission for a longer length of time than has been precertified, the attending physician must request the additional services or days.

To coordinate utilization management, your provider must call the provider number on the back of your ID card.

Previous Policy

Case Management

During preauthorization or utilization management review, patients are identified who may benefit from a nurse case manager to help prevent more significant health events. These cases are referred to case managers who then screen patients for program appropriateness. The case managers contact those patients to answer questions, check progress and make sure the patient is following the doctor's orders.