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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, 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.
  • 3. What other services require precertification or prior approval?

    Other services require precertification, prior approval, concurrent review or prior authorization. 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:

    • Ambulance – precertification required for transportation by fixed-wing aircraft (plane)
    • Autologous chondrocyte implantation, Carticel
    • BRCA genetic testing
    • Cardiac rhythm implantable devices
    • 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)
    • Cochlear device and/or implantation
    • Covered transplant surgeries
    • Dialysis visits – when request is initiated by an in-network provider, and dialysis to be performed at an out-of-network facility
    • Dorsal column (lumbar) neurostimulators: trial or implantation
    • Electric or motorized wheelchairs and scooters
    • Gastrointestinal (GI) tract imaging through capsule endoscopy
    • Gender reassignment surgery, even if rendered outside the 50 United States
    • Hip and knee arthroplasties
    • Hip surgery to repair impingement syndrome
    • Hyperbaric oxygen therapy
    • 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)
    • Lower limb prosthetics
    • Observation stays more than 24 hours
    • Orthognathic surgery procedures, bone grafts, osteotomies and surgical management of the temporomandibular joint (TMJ)
    • Osseointegrated implant
    • Osteochondral allograft/knee
    • Out-of-network freestanding ambulatory surgical facility services, when referred by an in-network provider
    • Pain Management such as facet and spinal injections
    • Pediatric Congenital Heart Surgery
    • Polysomnography (attended sleep studies)
    • Power morcellation with uterine myomectomy, with hysterectomy or for removal of uterine fibroids
    • Proton beam radiotherapy
    • Radiation oncology
    • Radiology imaging such as CT scans, MRIs, MRAs, and nuclear stress tests
    • Reconstructive or other procedures that may be considered cosmetic, such as:
      • Blepharoplasty/canthoplasty
      • Breast reconstruction/breast enlargement
      • Breast reduction/mammoplasty
      • Cervicoplasty
      • Excision of excessive skin due to weight loss
      • Gastroplasty/gastric bypass
      • Lipectomy or excess fat removal
      • Surgery for varicose veins, except stab phlebectomy
    • Spinal procedures, such as:
      • Artificial intervertebral disc surgery
      • Cervical, lumbar and thoracic laminectomy/laminotomy procedures
      • Spinal fusion surgery
    • Uvulopalatopharyngoplasty, including laser-assisted procedures
    • Ventricular assist devices
    • Video Electroencephalographic (EEG)

    For complete list refer to

  • 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.

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