Preadmission
Certification Program
Preadmission
certification verifies the medical necessity of an inpatient hospital admission
and the appropriate length of that admission
before
the individual is admitted. If an inpatient hospital admission is precertified,
the individual, the individual’s physician, the facility and the Trust
Office are informed, in advance, of the certified length of stay and that the
services are considered medically necessary. To receive benefits, the services
and supplies must be covered under this plan. If the reason for admission is
surgery, the individual may need a second surgical opinion (please see
Second
Surgical Opinion Program).
Obtaining
Preadmission Certification
When
an individual’s physician recommends an inpatient hospital admission, the
individual must call the medical review agency as soon as possible
but no later
than 48 hours before the scheduled
admission. The individual’s
physician or the facility ususally makes this call, but the ultimate
responsibility belongs to the individual.
The individual’s
physician’s treatment plan is reviewed by physicians and nurses who
compare it with accepted standards of medical care. The individual, the
individual’s physician, the facility, and the Trust Office are then
notified, in writing, of the medical review agency’s
determination.
Once the admission has been
certified and the individual is admitted to the facility, the medical review
agency monitors the stay. If additional inpatient days are requested, the
reviewer works with the individual’s physician and the facility to
determine if those additional days are medically necessary. This, in turn,
assures the individual that the additional certified days are covered by this
plan.
Emergency
Admissions
If an
emergency admission is necessary, the individual must contact the medical review
agency
within 48
hours of admission. If the individual
calls on the weekend or at night, the individual should leave a message on the
medical review agency’s answering machine. The message should include the
participant’s name, the patient’s name, a telephone number where the
participant or patient can be reached, the name of the facility, and the reason
for admission. With emergency admissions, the medical review agency assesses the
ongoing necessity of the inpatient stay.
Penalty
For Not Using the Preadmission Certification Program
If the
individual does
not
precertify an inpatient hospital admission, $50 is deducted from the covered
room and board expense for each day of inpatient care, up to a maximum of $250.
The admission must be medically necessary, and services and supplies must be
covered by this plan.
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