Preauthorization, Concurrent Review, and Retrospective Review

Preauthorization, concurrent review, and retrospective review are designed to help confirm:

• Your health care expenses are medically necessary under the Plan's rules,
• Your care is delivered in an efficient, cost-effective manner, and
• Your eligible medical expenses are reimbursable by the Plan.

Preauthorization means getting a decision — before you incur an expense — about whether a treatment is medically necessary under the Plan's rules. To avoid a benefit penalty, preauthorization is required for many services and products (see "Appendix C: Services and Products that Require Preauthorization"). To request preauthorization (also known as “precertification”), your provider must call Member Services at (855) 979-5192.

It is your responsibility to call Member Services to verify your provider has obtained preauthorization before receiving services. If so, Member Services can tell you the preauthorization number for your procedure (you should write it down for your records).

Preauthorization from the Plan is required only when the Plan is the primary plan. If another plan is primary (such as a health plan provided by your spouse’s employer), you should follow the preauthorization requirements of the primary plan. See “Coordination of Benefits” for information about which plan is primary.

Penalty for Failure to Obtain Preauthorization: If your provider does not obtain preauthorization when it is required, a 25% benefit penalty (100% benefit penalty for transplants) per event will be applied, reducing the amount the Plan will pay. In addition, if these services are later found not to be medically necessary, claims for reimbursement will be denied.

Example: Assume you get a CT scan and that the Health Plan would normally pay $1,000 for the scan. If your provider does not obtain preauthorization, the Plan will pay only $750 (assuming the scan is medically necessary). You may be responsible for the remaining $250 as your benefit penalty, in addition to any other expenses that are your responsibility under the Plan (such as deductibles and coinsurance).

Please also note the following two special rules:

• Failure to obtain preauthorization for a Human Organ or Bone Marrow Transplant will result in a 100% benefit penalty (in other words, the Plan will not cover any of the transplant expenses).
• Charges for the use of a robotic surgical system (for example, robot-assisted prostate surgery) are not eligible expenses unless such charges are specifically preauthorized by the Plan.

Preauthorization only means getting a decision that the requested services or supplies are deemed to be medically necessary under the Plan’s rules, which is a requirement for the expenses to be eligible for benefit payment under the Plan without a benefit penalty. The terms of the Health Care Program govern the extent to which expenses are eligible for benefit payment. You and your doctor are responsible for decisions about how to treat your medical condition and which providers to choose. Preauthorization is not intended to be a substitute for the medical judgment of your doctor or other health care providers.

It is important to note that:

• Preauthorization is not required for emergency services. Preauthorization is also not required for urgently needed care. Please note, however, that your provider is required to contact Member Services at (855) 979-5192 within two business days following an unscheduled inpatient admission, as discussed below. 
• Preauthorization is based upon the information presented by the member or his or her provider at the time preauthorization is requested. Preauthorization does not guarantee that the services and products a member receives are eligible for benefits under the Plan, or that each itemized charge will be covered.
• At the time the member’s claims are submitted, they will be reviewed in accordance with the terms of the Plan. The final determination of whether the services and products are eligible expenses will be made by the Plan and is subject to all conditions, exclusions, and limitations of the Plan. For example, if you receive preauthorization for inpatient care, the services and products you receive during your inpatient stay will be subject to review for compliance with Plan terms. If you receive excessive or unnecessary services, for example, the claims for those services are subject to denial even though the inpatient admission was preauthorized.

The following sections describe the services and supplies for which preauthorization is required to avoid a benefit penalty. For a detailed listing, see “Appendix C: Services and Products that Require Preauthorization.”

Inpatient Care – Scheduled and Unscheduled Admissions

To avoid a benefit penalty, preauthorization must be obtained for all scheduled inpatient admissions before the stay (except for certain childbirth stays) and for transition care when moving from one type of inpatient care to another (for example, moving from inpatient hospital care to a skilled nursing facility). For maternity admissions, preauthorization must be obtained only for stays longer than 48 hours following a vaginal delivery, or 96 hours following a cesarean section. To avoid a benefit penalty, if your maternity admission will extend beyond 48 hours following a vaginal delivery, or 96 hours following a cesarean section, preauthorization must be requested within two business days following the end of the 48-hour period (for a vaginal delivery) or 96-hour period (for a cesarean section). If the newborn’s inpatient stay will extend beyond 48 hours following a vaginal delivery, or 96 hours following a cesarean section, a separate preauthorization request must be made for the newborn within two business days following the end of the 48-hour period (for a vaginal delivery) or 96-hour period (for a cesarean section) to avoid a benefit penalty.

The process for requesting this preauthorization is described in the section “Preauthorization Process for Scheduled Care.”

For unscheduled admissions, such as an admission following emergency room care, preauthorization must be requested within the next two business days (except as required by applicable law). The process for requesting this preauthorization is described in the section “Preauthorization Process for Unscheduled Admissions.”

If your provider requests to extend care beyond the preauthorized length of stay and that request involves urgently needed care, Member Services will notify you or your provider whether the extended stay is medically necessary within 24 hours, as long as the request is made at least 24 hours before the end of the preauthorized length of stay. If the request does not involve urgently needed care, the normal timeframes for responding to a preauthorization request will apply.

For purposes of the preauthorization requirements, following are examples of facility types considered to be “inpatient admissions.” This list of examples is not exhaustive and may change from time to time.

• Birthing Center 
• Comprehensive Inpatient Rehabilitation Facility 
• End-Stage Renal Disease Treatment Facility 
• Hospice 
• Inpatient Hospital 
• Inpatient Psychiatric Facility 
• Residential Substance Abuse Treatment Facility 
• Psychiatric Residential Treatment Facility 
• Skilled-Nursing Facility 

Outpatient Care

To avoid a benefit penalty, preauthorization must be obtained for certain outpatient care. Outpatient care may be provided in a variety of settings, such as a physician’s office, your home, an ambulatory surgery center, or an imaging center. But it can also be provided in a hospital, such as when you are getting outpatient surgery, lab tests, or X-rays. For purposes of the preauthorization requirements, the following are examples of outpatient facility types in which care must be preauthorized. This list of examples is not exhaustive and may change from time to time.

• Home 
• Off-Campus Outpatient Hospital 
• On-Campus Outpatient Hospital 
• Ambulatory Surgical Center 

Services (including routine visits or procedures) performed in a physician’s office (POS 11) do not require preauthorization unless the services are specifically listed in "Appendix C: Services and Products That Require Preauthorization."

A detailed listing of specific outpatient services requiring preauthorization is in "Appendix C: Services and Products That Require Preauthorization" (this list is updated periodically). The process for requesting this preauthorization is described in the section “Preauthorization Process for Scheduled Care.”

After reviewing Appendix C, if you still have questions about whether a specific outpatient service requires preauthorization, call Member Services at (855) 979-5192.

Durable Medical Equipment

To avoid a benefit penalty, preauthorization must be obtained for certain types of durable medical equipment items, as listed in “Appendix C: Services and Products that Require Preauthorization,” whether purchased or rented. The process for requesting this preauthorization is described in the next section. 

Preauthorization Process for Scheduled Care

When preauthorization is required for scheduled care (scheduled admission, outpatient care, and durable medical equipment as described above), your provider must request preauthorization by calling Member Services at (855) 979-5192 as soon as possible before the procedure, inpatient admission, outpatient service, purchase or rental of durable medical equipment, or transition care (for example, from inpatient hospital care to a skilled nursing facility, home health care, or hospice care).

When preauthorization is requested for scheduled care, the Plan's Utilization Management (UM) Department will provide a written response within 15 days, unless additional time is needed. If additional time is needed, the UM Department will notify you within the original 15 days that additional time is necessary. Please keep this response period in mind when requesting preauthorization. If your provider does not allow enough time for your request to be reviewed, you may not receive preauthorization and the benefit penalty may be applied, reducing the amount the Plan will pay.

If the Plan’s UM Department requests additional information from you, you will have 45 days to provide the information. The Plan’s UM Department will provide a written response within 15 days of receiving the additional information.

When the Plan’s UM Department preauthorizes scheduled care, they will provide you and/or your provider with a preauthorization number, beginning with “EPS.”

If you disagree with the Plan’s UM Department's determination regarding your preauthorization request, you can file an appeal. See "How to File a Claim" for more information about the claim and appeals process.

Please note: When your provider requests preauthorization on your behalf, the Plan may communicate directly with that provider to facilitate the review process. However, verifying preauthorization remains your responsibility.

Preauthorization Process for Unscheduled Admissions

If your admission to the hospital is unscheduled — such as an admission from the emergency room — your provider may not be able to request preauthorization before your admission occurs. In that situation, your provider must call Member Services at (855) 979-5192 within the first two business days after the admission. (For example, if you go to the emergency room on Friday night and are admitted to the hospital on Saturday, your provider should call Member Services by 5 p.m. CT on Tuesday.) Outside of business hours, your provider may leave a confidential voice mail message.

Please note: There is a limited exception to this requirement for situations in which you are admitted to a Non-Direct hospital with respect to a visit in which you received emergency services and have been stabilized. Though a preauthorization request is not formally required in this situation, your provider is requested to call Member Services as soon as possible. 

When preauthorization is requested for an unscheduled inpatient admission, the Plan’s UM Department will provide a response to the preauthorization request within 72 hours, unless additional time is needed. If additional time is needed, the Plan’s UM Department will notify you within the first 24 hours that additional time is necessary.

If the Plan’s UM Department requests additional information from you, you will have a minimum of 48 hours to provide the information. The Plan’s UM Department will provide a response within 48 hours of whichever of the following events occurs first:

• Receipt of the additional information, or
• The end of the time period you were given to provide additional information.

The Plan’s UM Department responses may be issued orally, in which case a written response will also be provided within three days of the oral notification.

When the Plan’s UM Department preauthorizes an unscheduled admission, they will provide you and/or your provider with a preauthorization number, beginning with “EPS.”

If you disagree with the Plan’s UM Department's determination regarding your preauthorization request, you can file an appeal. See "How to File a Claim" for more information about the claim and appeals process.

Please note: When your provider requests preauthorization on your behalf, the Plan may communicate directly with that provider to facilitate the review process. However, verifying preauthorization remains your responsibility.

Concurrent Review

The Plan provides concurrent review to determine whether the services you are receiving during an ongoing course of treatment (such as a hospitalization or a course of physical therapy sessions) are medically necessary. Concurrent review monitors your inpatient care and coordinates the scheduled release with you, your providers, and any alternative care you may need. Concurrent review can also identify other courses of treatment, such as home health care and home intravenous therapy.

Retrospective Review

If preauthorization was not obtained and services were provided without a review, a retrospective review will be required to determine if services were medically necessary. When you or your provider request a retrospective review for post-service care, the Plan's Utilization Management (UM) Department will provide a written response to your or your provider's retrospective review request within 30 days. This period may be extended one time by the Plan’s UM Department for up to 15 days provided that the Plan’s UM Department determines that an extension is necessary because of matters beyond the control of the organization; and notifies you or your provider prior to the expiration of the initial 30 days period of the circumstances requiring the extension and the date when the Plan expects to make a decision. If additional information is necessary to decide the retrospective review, you will receive written notice of the specific information needed prior to the initial 30-day period.  You will have 45 days from receipt of the notice to provide the information. You will receive notification of the benefit determination within 15 days following receipt of the additional information.  Retrospective reviews cannot be requested to be reviewed urgently, since the service has already been provided.

If a request for retrospective review is denied, in whole or in part, you or your beneficiary(s) will receive written notice of the decision.  The written notice will include information similar to what is provided for a denied claim, as described in Benefit Determinations.

Requesting a retrospective review does not waive the penalty for failure to obtain preauthorization. If your provider does not obtain preauthorization when it is required, a 25% benefit penalty (100% benefit penalty for transplants) per event will be applied, reducing the amount the Plan will pay. In addition, if these services are later found not to be medically necessary (i.e., during retrospective review), claims for reimbursement will be denied.