Introduction
Two of the
largest categories of medical expenses for this plan are hospitalization and
surgery. To help control these expenses, the plan contracts with a medical
review agency to administer the plan’s medical review
program. The
medical review program is designed to let an individual and the
individual’s physician know whether certain admissions and surgeries are
medically necessary and covered by the plan
before
the individual undergoes treatment and incurs expenses. The medical review
program includes the following:
- Preadmission
certification for inpatient hospital admissions.
- Second
surgical opinions for certain surgical procedures.
- Medical
case management for certain medical
conditions.
An
individual must use the medical review program even if he or she has other
insurance (except Medicare).
Failure
to use the medical review program may result in a reduction in
benefits.
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