Your Plan includes the processes of Pre-Service, Concurrent and Retrospective Reviews to determine when services should be covered by your Plan. Their purpose is to promote the delivery of cost-effective medical care by reviewing the use of procedures and, where appropriate, the setting or place of service that they are performed. Your Plan requires that Covered Services be Medically Necessary for benefits to be provided. When setting or place of service is part of the review, services that can be safely provided to you in a lower cost setting will not be Medically Necessary if they are performed in a higher cost setting. Prior Authorization: Network Providers are required to obtain prior authorization in order for you to receive benefits for certain services. Prior authorization criteria will be based on multiple sources
Administrator may determine that a service that was initially prescribed or requested is not Medically Necessary if you have not previously tried alternative treatments which are more cost effective.
If you have any questions regarding the information contained in this section, you may call the Precertification telephone number on the back of your Identification Card or visit www.anthem.com.
Types of Requests:
Precertification – A required review of a service, treatment or admission for a benefit coverage
determination which must be obtained prior to the service, treatment or admission start date. For emergency admissions, you, your authorized representative or Physician must notify the
Administrator within 48 hours of the admission or as soon as possible within a reasonable period of time. For childbirth admissions, Precertification is not required unless there is a complication and/or the mother and baby are not discharged at the same time.
Predetermination – An optional, voluntary Prospective or Concurrent request for a benefit coverage
determination for a service or treatment. The Administrator will review your Benefit Booklet to determine if there is an exclusion for the service or treatment. If there is a related clinical coverage guideline, the benefit coverage review will include a review to determine whether the service meets the definition of Medical Necessity under this Benefit Booklet or is Experimental/Investigative as that term is defined in this Benefit Booklet.
Medical Review – A Retrospective review for a benefit coverage determination to determine the
Medical Necessity or Experimental/Investigative nature of a service, treatment or admission that did not require Precertification and did not have a Predetermination review performed. Medical Reviews occur for a service, treatment or admission in which the Administrator has a related clinical coverage guideline and are typically initiated by the Administrator.
Most Network Providers know which services require Precertification and will obtain any required Precertification or request a Predetermination if they feel it is necessary. Your Primary Care Physician and other Network Providers have been provided detailed information regarding Health Care
Management procedures and are responsible for assuring that the requirements of Health Care Management are met. The ordering Provider, facility or attending Physician will contact the Administrator to request a Precertification or Predetermination review (“requesting Provider”). The Administrator will work directly with the requesting Provider for the Precertification request. However, you may designate an authorized representative to act on your behalf for a specific request. The
authorized representative can be anyone who is 18 years of age or older.
Who is responsible for Precertification Services provided by a Net-
work Provider Services provided by a BlueCard/Non-Network/Non-Participating Provider
Provider • Member is responsible for Precertification.
• Member is financially responsible for service and/or set- ting that are/is not covered under the Plan based on an Adverse Determination of Medical Necessity or Experimen- tal/Investigative.
The Administrator will utilize its clinical coverage guidelines, such as medical policy and other internally developed clinical guidelines, and preventative care clinical coverage guidelines, to assist in making Medical Necessity decisions. These guidelines reflect the standards of practice and medical
interventions identified as appropriate medical practice. The Administrator reserves the right to review and update these clinical coverage guidelines periodically. Your Benefit Booklet and the Administrative Services Agreement take precedence over these guidelines.
You are entitled to receive, upon request and free of charge, reasonable access to any documents relevant to your request. To request this information, contact the Precertification telephone number on the back of your Identification Card.
The Administrator may, from time to time, waive, enhance, modify or discontinue certain medical management processes (including utilization management, case management, and disease management) if in the Administrator’s discretion, such change is in furtherance of the provision of cost effective, value based and/or quality services.
In addition, the Administrator may select certain qualifying Providers to participate in a program that exempts them from certain procedural or medical management processes that would otherwise apply. The Administrator may also exempt your claim from medical review if certain conditions apply.
Just because the Administrator exempts a process, Provider or claim from the standards which otherwise would apply, it does not mean that the Administrator will do so in the future, or will do so in the future for any other Provider, claim or Member. The Administrator may stop or modify any such exemption with or without advance notice.
You may determine whether a Provider is participating in certain programs contacting customer service number on the back of your ID card.