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 may make 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 retiree’s name, the individual’s name, a
telephone number where the retiree or individual can be reached, the name of the
facility, and the reason for admission. With emergency admissions, the medical
review agency assesses the ongoing medical necessity of the inpatient
stay.
Penalty For
Not Using The Preadmission Certification Program
If an 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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