ASBAIT and your employer want you to get the best, most appropriate care, when and where you need it. That’s why your plan includes the extra expertise of ASBAIT’s Medical Management program. The Medical Management nurses are like personal health consultants who can help you make decisions about certain types of care you and your doctor may be considering. Registered nurses review treatment plans, then help to assure that you get the right treatment in the right setting, when you need it.
How to Obtain Precertification
For non-emergency procedures and hospital admissions: The covered person or the physician must contact Medical Management prior to the admission or in advance of the procedure. Often times this is done by your physician, but it is the member’s responsibility to make sure that all required precertifications are completed. Medical Management will review the request for services and contact the physician for any records or additional information necessary to thoroughly evaluate the need for services.
For emergency procedures or hospital admissions: The covered person, the physician, the hospital admissions clerk or anyone associated with the covered person’s treatment, must notify Medical Management by telephone within 48 hours of the procedure or admission.
Precertification of a procedure does not guarantee benefits. All benefit payments are determined by Meritain Health, in accordance with the provisions of this plan. The program is designed as a cost-containment program to maximize the plan benefits and reduce unnecessary hospitalizations, surgical procedures and other diagnostic services. Once a precertification has been received, it is valid for a period of 90 days.
What Requires Precertification
The following items and/or services must be precertified before any medical services are provided:
- All inpatient facility admissions
- Outpatient and physician surgery
- Outpatient and physician diagnostic services
- Non-orthopedic CT and MRI
- PET scan, sleep study
- Chemotherapy (including oral)
- Radiation therapy
- Oncology and transplant-related injections, infusions and treatments
- Dialysis
- Hyperbaric oxygen
- Home health care
- Durable medical equipment, limited to electric/motorized scooters or wheelchairs and pneumatic compression devices
- High-cost drugs: injectables that cost $2,000 or more per drug, per month
- Infusion therapies that cost $2,000 or more per drug, per month
For an all-inclusive list, please refer to your plan document.
Failure to comply with the precertification requirements may result in penalties which you will be responsible for. A 20 percent reduction in benefits may be taken, or you may be disqualified from benefits altogether. Your doctor may request precertification for you, however you are ultimately responsible for making sure precertification is obtained when required.