Health & Security Retiree Health Plan > SPD > Preadmission Certification Program

Summary Plan Description

Preadmission Certification Program

This Section Is For Individuals Without Medicare
Preadmission certification verifies the medical necessity of an inpatient hospital admission and the appropriate length of that admission before you are admitted. If an inpatient hospital admission is precertified, you, your 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 by this plan. If the reason for admission is surgery, you may need a second surgical opinion (please see "Second Surgical Opinion Program" on pages 44-46).

Key Point

The medical review agency advises the plan on the medical necessity of a recommended inpatient hospital admission, surgery, or ongoing treatment plan. To receive benefits, the services and supplies must be covered by this plan and you must be eligible when the services are provided.

Obtaining Preadmission Certification

When your physician recommends an inpatient hospital admission, you must call the medical review agency as soon as possible but no later than 48 hours before the scheduled admission. Your physician's treatment plan is reviewed by physicians and nurses who compare it with accepted standards of medical care. You, your physician, the facility, and the Trust Office are then notified, in writing, of the medical review agency's determination.

When the admission has been certified and you are admitted to the facility, the medical review agency monitors the stay. If additional inpatient days are requested, the reviewer works with your physician and the facility to determine if those additional days are medically necessary.

Key Point

All inpatient hospital admissions must be precertified with the medical review agency before you are admitted. Please call the appropriate telephone number on your Medical & Prescription ID Card.

Emergency Admissions

If an emergency admission is necessary, you must contact the medical review agency within 48 hours of admission. If you call on the weekend or at night, you should leave a message on the medical review agency's answering machine. The message should include your (the retiree's) name, the patient's name, a telephone number where you or the patient 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 you do 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.

Helpful Hint

When your physician recommends an inpatient hospital admission, you must call the medical review agency as soon as possible but no later than 48 hours before the scheduled admission.