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Q1: As a resident, what are my precertification requirements?
You can call Customer Service (see the number on your ID card) or check your plan booklet to determine whether your plan has a precertification requirement. If it does, the following applies:
All Inpatient Hospitalizations and procedures done at an Outpatient Surgery Facility must be pre-certified.
To comply with the pre-certification requirements, the Covered Person must:
Contact the professional review organization at the telephone number contained in the Insured's Certificate (1-866-344-6746) as soon as possible before the expense is to be incurred
Comply with the instructions of the professional review organization and submit any information or documents they require
Notify all Doctors, Hospitals and other providers that this insurance contains pre-certification requirements and ask them to fully cooperate with the professional review organization
If the Covered Person complies with the pre-certification requirements, and the expenses are pre-certified, the Company will pay Eligible Expenses subject to all terms, conditions, provisions and exclusions described in the plan booklet.
If the Covered Person does not comply with the pre-certification requirements, or if the expenses are not pre-certified, a penalty may apply, which may consist of a reduction of Eligible Expenses or a reduction of benefit. See your plan booklet for more detail.
Emergency pre-certification: In the event of an emergency Hospital admission, pre-certification must be made within 48 hours after the admission, or as soon as is reasonably possible.
Concurrent Review – For Inpatient stays of any kind, the professional review organization will pre-certify a limited number of days of confinement. Additional days of Inpatient confinement may later be pre-certified if a Covered Person receives prior approval.
Pre-certification Does Not Guarantee Benefits – The fact that expenses are pre-certified does not guarantee either payment of benefits or the amount of benefits. Eligibility for and payment of benefits are subject to all the terms, conditions, provisions and exclusions herein.
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