PPO

Services for which precertification is required

Precertification of hospital and other institutional services with the Medical Management Program (telephone: 1 (800) 982-8089) is required. The reason for this is constructive, as pre-certification ensures that (a) all expenses related to the hospitalization or treatment will be covered and (b) that a hospitalization case is medically monitored from the first day of admission so that if complications should arise, or if after-hospital care should be required, the case may be managed promptly and effectively.

The Blue Cross programme may impose a benefit penalty for failure to precertify a service when required. Therefore it is important that you take note of the circumstances when precertification is required.

When to call the Medical Management Program

• At least two weeks prior to any planned surgery or hospital admission. This applies to ambulatory surgery as well as in-patient surgery;
• Within 24 hours of an emergency hospital admission;
• Within the first three months of pregnancy and no more than one business day after the actual delivery;
• Prior to receiving home health care or home infusion therapy services (the network vendor must call medical management to pre-certify benefits);
• Prior to admission to a skilled nursing facility;
• Prior to receiving hospice care;
• Prior to receiving physical, occupational, speech or vision therapy;
• Prior to receiving air ambulance service;
• Prior to cardiac rehabilitation;
• Prior to renting or purchasing durable medical equipment, prosthetics or orthotics (the network vendor must call medical management to pre-certify);
• Prior to undergoing magnetic resonance imaging scans (MRIs).
  With respect to mental health care and alcohol and substance abuse treatments, pre-approval must be sought from Magellan Behavioral Health (telephone: 1 (800) 626-3643).

Medical Management penalties

If you do not comply with the Medical Management requirement, your hospital/facility benefits may be reduced as follows (does not apply for providers outside the United States):

• In-patient hospital admissions, ambulatory surgery, cardiac rehabilitation and home health care, hospice care, occupational speech and vision therapy, physical therapy, MRIs, and skilled nursing facilities - 50 per cent up to $2,500 maximum per admission;
• Home infusion therapy and prosthetics, orthotics and durable medical equipment (vendor is penalized, member is held harmless).

Home health care

Home health care is covered at 100 per cent and is limited annually to 200 visits of up to 4 hours per visit. To be eligible for reimbursement, home health care must be prescribed by a physician and determined to be medically necessary. A written prescription or home health care treatment plan is required as well as any supporting documentation from the physician to facilitate Empire Blue Cross' review of a claim for the payment of benefits. It is also a requirement (subject to a monetary penalty) that proposed home health care services be submitted to the Blue Cross Medical Management Program for a predetermination of benefits payable prior to contracting with a nursing or home health care agency. Services provided at home need not follow a hospital confinement.

It is important to note that covered home health care services exclude all types of custodial care services. Custodial care services are categorized as personal care and comprise services designed to help a person perform activities of daily living, which include assistance with bathing, eating, dressing, toileting, continence and transferring. Such services are performed at home or in other facilities such as nursing homes, adult day-care centres and assisted living facilities. Custodial care services may be of a short-term nature or provided on a long-term basis. Health insurance plans, including the Empire Blue Cross PPO plan, provide no coverage for custodial care.

Worldwide participating Blue Cross hospitals

Subscribers to Empire Blue Cross health insurance plans have the benefit of a network of hospitals worldwide which accept the Empire Blue Cross ID card and which bill Empire Blue Cross directly for any medical services rendered. A list of these hospitals may be obtained by going to the following Internet site:

https://international.worldaccess.com/bcbsa/index.asp?page=home.

Upon accessing Blue Cross worldwide hospitals, you will obtain instructions regarding how to proceed when you need health care outside of the United States, in addition to being able to view a list of Blue Cross worldwide hospitals.