skip to main content
Woman on Beach

Frequently Asked Questions

Claims Questions

Precertification Questions

  • 1. How do I precertify for a hospital admission?

    You, your representative, your doctor, or your hospital must call us prior to admission. The toll-free number is 800-593-2354. 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.

  • 2. Do I still need to precertify for hospital admission?

    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 or residential treatment care by $500 if no one contacts us for precertification. If the stay is not medically necessary, we will not pay any benefits.

    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.
  • 3. What other services require preauthorization?

    Other services require precertification, preauthorization, concurrent review or prior authorizaton. You, your representative, your doctor, or treating facility must call us at 800-593-2354 (except for prior authorization on prescription drugs – see below) before the admission or care, such as:

    • All High End Radiology procedures, such as but not limited to CT Scan, PET Scan, SPECT, MRI, except in the case of an accident or a medical emergency
    • Chemotherapy and radiation therapy
    • Home health services
    • Transgender surgical services (gender reassignment surgery) to treat gender dysphoria, even if rendered outside the 50 United States
    • Organ/tissue transplants
    • Extended care/Skilled nursing facility admission
    • Partial hospitalization for mental health or substance abuse treatment
    • Prescription drugs. Some medications are not covered unless you receive approval through a coverage review (prior authorization). This review uses Plan rules based on FDA-approved prescribing and safety information, clinical guidelines and uses that are considered reasonable, safe, and effective.

    If no one contacted us for specified services such as Home health care, Hospice care, or Skilled nursing facility care, we will pay a reduced benefit as referenced in the appropriate benefit section of our Brochure.

    Note: We do not require precertification, preauthorization, or concurrent review if you receive treatment outside the 50 United States (including Guam), except as noted above. However, the Plan will review all services to establish medical necessity. We may request medical records in order to determine medical necessity.

  • 4. What do I do in case of an emergency?

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

Network Providers Questions

ID Cards Questions