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, an
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 contact the patient to 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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