ADMISSION CERTIFICATION. Pre‐Admission Certification applies when you need to be admitted to a Hospital as an Inpatient in other than an emergency situation. Prior to your admission, your Primary Care Physician or Woman's Principal Health Care Provider must obtain approval of your admission from the Participating IPA/Participating Medical Group with which he/she is affiliated or employed. The Participating IPA/Partici pating Medical Group may recommend other courses of treatment that could help you avoid an Inpatient stay. It is your responsibility to cooperate with any recom mendations made by the Participating IPA/Participating Medical Group.
ADMISSION CERTIFICATION. Under the Pre-Admission Certification/Concurrent Review Program, the doctor’s recommendation for non-emergency hospitalization is reviewed and “pre-certified” before the individual is admitted to the hospital. Any elective non-emergency hospital stay (including maternity admissions) must be pre-certified. Failure to follow the pre-admission procedure may result in the patient paying the first two hundred dollars ($200) of room and board charges. The admission procedure must be followed for emergency care within forty-eight (48) hours after the emergency.
ADMISSION CERTIFICATION. Pre‐Admission Certification applies when you need to be admitted to a Hospital as an Inpatient in other than an emergency situation. Prior to your admission, your Primary Care Physician or Woman's Principal Health Care Provider must obtain approval of your admission from the Participating IPA/Participating Medical Group with which he/she is affiliated or employed. The Participating IPA/Participating Medical Group may recommend other courses of treatment that could help you avoid an Inpatient stay. It is your responsibility to cooperate with any recommendations made by the Participating IPA/Participating Medical Group. CONCURRENT REVIEW Once you have been admitted to a Hospital as an Inpatient, your length of stay will be reviewed by the Participating IPA/Participating Medical Group. The purpose of that review is to ensure that your length of stay is appropriate given your diagnosis and the treatment that you are receiving. This is known as Concurrent Review. If your Hospital stay is longer than the usual length of stay for your type of condition, the Participating IPA/Participating Medical Group will contact your Primary Care Physician or Woman's Principal Health Care Provider to determine whether there is a medically necessary reason for you to remain in the Hospital. Should it be determined that your continued stay in the Hospital is not medically necessary, you will be informed of that decision, in writing, and of the date that your benefits for that stay will end. EXCLUSIONS—WHAT IS NOT COVERED Expenses for the following are not covered under your benefit program:
ADMISSION CERTIFICATION. Pre‐Admission Certification applies when you need to be admitted to a Hospital as an Inpatient in other than an emergency situation. Prior to your admission, your Primary Care Physician or Woman's Principal Health Care Provider must obtain approval of your admission from the Participating IPA/Participating Medical Group with which he/she is affiliated or employed. The Participating IPA/Parti- cipating Medical Group may recommend other courses of treatment that could help you avoid an Inpatient stay. It is your responsibility to cooperate with any recommendations made by the Participating IPA/Participating Medical Group. CONCURRENT REVIEW Once you have been admitted to a Hospital as an Inpatient, your length of stay will be reviewed by the Participating IPA/Participating Medical Group. The pur- pose of that review is to ensure that your length of stay is appropriate given your diagnosis and the treatment that you are receiving. This is known as Concurrent Review. If your Hospital stay is longer than the usual length of stay for your type of condi- tion, the Participating IPA/Participating Medical Group will contact your Primary Care Physician or Woman's Principal Health Care Provider to determine whether there is a medically necessary reason for you to remain in the Hospital. Should it be determined that your continued stay in the Hospital is not medically necessary, you will be informed of that decision, in writing, and of the date that your benefits for that stay will end. EXCLUSIONS — WHAT IS NOT COVERED Expenses for the following are not covered under your benefit program: — Services or supplies that were not ordered by your Primary Care Physician or Woman's Principal Health Care Provider except as explained in the EMERGENCY CARE BENEFITS section, SUBSTANCE USE DIS- ORDER TREATMENT BENEFITS section, HOSPITAL BENEFITS section, PEDIATRIC VISION CARE BENEFITS section, PEDIATRIC DENTAL CARE BENEFITS section and, for Mental Illness (other than Serious Mental Illness) or routine vision examinations in the PHYSICIAN BENEFITS section of this Certificate. — Services or supplies that were received prior to the date your coverage began or after the date that your coverage was terminated, unless otherwise stated in this Certificate. — Services or supplies for which benefits have been paid under any Workers' Compensation Law or other similar laws whether or not you make a claim for such compensation or receive such benefits. However, this exclusion shall not apply i...
ADMISSION CERTIFICATION. Notification must be given to Blue Cross and Blue Shield of Nebraska of a nonelective admission or emergency admission. Notification must be given within 24 hours of the admission, or the next day, whichever occurs first. If Inpatient certification of benefits is denied, the Allowable Charges otherwise considered for benefit payment under this Contract for all Covered Services associated with this hospitalization will be reduced by fifty percent (50%). If the Member does not request precertification, the Allowable Charges otherwise considered for benefit payment by this Contract for Hospital Covered Services associated with this hospitalization will be reduced by $500.00.
ADMISSION CERTIFICATION. Continued Stay Review Inpatient hospital admissions require Pre-Admission Certification and Continued Stay Review (PAC/CSR) $400 Penalty for non-compliance. To pre-certify, call 0-000-000-0000 Case Management - Voluntary Program This is a service designed to provide assistance to a patient who is at risk of developing medical complications or for whom a health incident has precipitated a need for rehabilitation or additional health care support. The program strives to attain a balance between quality and cost effective care while maximizing the patient's quality of life. 0-000-000-0000
