Member FAQs

You, your representative, your doctor, or your hospital must call us prior to admission. The toll-free number is 1-800-593-2354 (TTY: 711). Provide the following information:

• Enrollee’s name and Plan identification number
• Patient’s name, birth date and phone number
• Reason for proposed hospital stay
• Name and phone number of the doctor who will admit you
• Name of hospital or facility
• Number of planned days in the hospital

We’ll tell the doctor and hospital the number of days in which the patient is approved to stay in the hospital. Our decision will be sent to you, your doctor, and the hospital.

Yes. The federal government requires that all members of a fee-for-service plan must precertify their hospital admissions. We will reduce our benefits for the inpatient hospital stay, Skilled Nursing Facility stay or residential treatment care by $500 if no one contacts us for precertification. If the stay is not medically necessary, we will only pay for any covered medical services and supplies that are otherwise payable on an outpatient basis.

Exceptions: You do not need precertification in these cases:

• You are admitted to a hospital or residential treatment center outside the 50 United States. However, the Plan will review all services to establish medical necessity. We may request medical records in order to determine medical necessity.
• You have another group health insurance policy that is the primary payer for the hospital stay.
• Medicare Part A is the primary payer for the hospital stay. Note: If you exhaust your Medicare hospital benefits and do not want to use your Medicare lifetime reserve days or you have no Medicare lifetime reserve days left, then we become the primary payer and you must precertify.

Note: if you use a network provider, they should handle the precertification process.

Other services require precertification, prior approval, concurrent review or prior authorization. You, your representative, your doctor, or treating facility must call us at 1-800-593-2354 (TTY: 711).  (except for prior authorization on prescription drugs – see below) before the admission or care, such as, but not limited to:

• Ambulance – precertification required for transportation by fixed-wing aircraft (plane)
• BRCA genetic testing
• Certain mental health services, inpatient admissions, Residential treatment center (RTC) admissions, Partial hospitalization programs (PHPs), Intensive outpatient programs (IOPs), Psychological testing, Neuropsychological testing, Outpatient detoxification, Transcranial magnetic stimulation (TMS) and Applied Behavior Analysis (ABA – even if rendered outside the 50 United States)
• Gender reassignment surgery, even if rendered outside the 50 United States
• Inpatient confinements (except hospice). For example, surgical and non-surgical stays; stays in a skilled nursing or rehabilitation facility; and maternity and newborn stays that exceed the standard length of stay (LOS)
• Observation stays more than 24 hours
• Radiation oncology
• Radiology imaging such as CT scans, MRIs, MRAs, and nuclear stress tests

For complete list, see section 3 'How you get care' in the
Official Plan brochure.

When there is an emergency admission you, your representative, the doctor, or the hospital must call 1-800-593-2354 (TTY: 711), within two business days after the day of admission, even if the patient has been discharged from the hospital.