Benefits Management Program. The Benefits Management Program applies utilization man- agement and case management principles to assist Members and providers in identifying the most appropriate and cost- effective way to use the Benefits provided under this health plan. The Benefits Management Program includes prior authoriza- tion requirements for inpatient admissions, selected inpatient and outpatient services, office-administered injectable drugs, and home-infusion-administered drugs, as well as emergency admission notification, and inpatient utilization management. The program also includes Member services such as, dis- charge planning, case management and, palliative care ser- vices. The “Prior Authorization List” is a list of medical services and drugs that require prior authorization. Members are en- couraged to work with their providers to obtain prior authori- zation. Members and providers may call Customer Service at the number provided on the back page of this Evidence of Coverage to inquire about the need for prior authorization. Providers may also access the Prior Authorization List on the provider website. The following sections outline the Member’s responsibilities under the Benefits Management Program. The Benefits Man- agement Program applies to all Members. Prior authorization allows the Member and provider to verify with Blue Shield that (1) the proposed services are a Benefit of the Member’s plan, (2) the proposed services are Medical- ly Necessary, and (3) the proposed setting is clinically appro- priate. The prior authorization process also informs the Member and provider when Benefits are limited to services rendered by a Participating Provider (See the Summary of Benefits). The Member or provider should call Customer Service at the number provided on the back page of this Evidence of Cov- erage for prior authorization of non-emergency medical Hos- pital admissions and all medical services and drugs included in the Prior Authorization List (except for radiological and nuclear imaging procedures). Prior authorization for radiolog- ical and nuclear imaging procedures and Mental Health Ser- vices is addressed separately in the following Prior Authori- zation for Radiological and Nuclear Imaging Procedures and Prior Authorization for Mental Health Hospital Admissions and Non-routine Outpatient Services sections. A decision will be made on all requests for prior authoriza- tion within five business days from receipt of the request. The treating provider will be notifi...
Benefits Management Program. The Benefits Management Program applies utilization management and case management principles to assist Members and providers in identifying the most appropriate and cost-effective way to use the Benefits provided under this health plan. The Benefits Management Program includes prior authorization requirements for inpatient admissions, selected inpatient and outpatient services, office- administered injectable drugs, and home-infusion- administered drugs, as well as emergency admission notification, and inpatient utilization management. The program also includes Member services such as, discharge planning, case management and, palliative care services. The following sections outline the requirements of the Benefits Management Program.
Benefits Management Program. The Benefits Management Program applies utilization management and case management principles to assist Members and providers in identifying the most appropriate and cost- effective way to use the Benefits provided under this health plan. The Benefits Management Program includes prior authorization requirements for inpatient admissions, selected inpatient and outpatient services, office-administered injectable drugs, and home-infusion-administered drugs, as well as emergency admission notification, and inpatient utilization management. The program also includes Member services such as, discharge planning, case management and, palliative care services. The “Prior Authorization List” is a list of medical services and drugs that require prior authorization. Members are encouraged to work with their providers to obtain prior authorization. Members and providers may call Customer Service at the number provided on the back page of this Evidence of Coverage to inquire about the need for prior authorization. Providers may also access the Prior Authorization List on the provider website. The following sections outline the Member’s responsibilities under the Benefits Management Program. The Benefits Management Program applies to all Members.
Benefits Management Program. The Benefits Management Program applies uti- lization management and case management princi- ples to assist Members and providers in identify- ing the most appropriate and cost-effective way to use the Benefits provided under this Health Plan. The Benefits Management Program includes prior authorization requirements for various medical benefits, including inpatient admissions, outpa- tient services, and prescription Drugs administered in the office, infusion center or provided by a home infusion agency, as well as emergency admission notification, and inpatient utilization management. The program also includes Member services such as, discharge planning, case management and, pal- liative care services. The following sections outline the requirements of the Benefits Management Program.
Benefits Management Program. (a)(1) Pre-certification will be required for all elective inpatient confinements and prior to certain specified medical procedures to provide an opportunity for a review of diagnostic procedures for appropriateness of setting and effectiveness of treatment alternatives.
Benefits Management Program. The Benefits Management Program applies utilization management and case management principles to assist Members and providers in identifying the most appropriate and cost-effective way to use the Benefits provided under this health plan. The Benefits Management Program includes prior authorization requirements for inpatient admissions, selected inpatient and outpatient services, office-administered injectable drugs, and home-infusion-administered drugs, as well as Prior authorization allows the Member and provider to verify with Blue Shield or Blue Shield’s MHSA that (1) the proposed services are a Benefit of the Member’s plan, (2) the proposed services are Medically Necessary, and (3) the proposed setting is clinically appropriate. The prior authorization process also informs the Member and provider when Benefits are limited to services rendered by Participating Providers or MHSA Participating Providers (See the Summary of Benefits). A decision will be made on all requests for prior authorization within five business days from receipt of the request. The treating provider will be notified of the decision within 24 hours and written notice will be sent to the Member and provider within two business days of the decision. For urgent services when the routine decision making process might seriously jeopardize the life or health of a Member or when the Member is experiencing severe pain, a decision will be rendered as soon as possible to accommodate the Member’s condition, not to exceed 72 hours from receipt of the request. (See the Outpatient Prescription Drug Benefits section for specific information about prior authorization for outpatient prescription drugs). If prior authorization was not obtained, and services provided to the Member are determined not to be a Benefit of the plan or were not medically necessary, coverage will be denied. Prior authorization is required for radiological and nuclear imaging procedures. The Member or provider should call 0-000-000-0000 for prior authorization of the following radiological and nuclear imaging procedures when performed within California on an outpatient, non-emergency basis:
Benefits Management Program. (a) Pre-certification shall be required for all elective inpatient confinements and prior to certain specified medical procedures to provide an opportunity for a review of diagnostic procedures for appropriateness of setting and effectiveness of treatment alternatives. Pre-certification will be required prior to maternity admissions in order to highlight appropriate prenatal services and reduce costly and traumatic birthing complications.
(1) A call to the Benefits Management Program will be required within 48 hours of admission for all emergency or urgent admissions to permit early identification of potential "case management" situations.
(2) Precertification will be required prior to an admission to a Skilled Nursing Facility (SNF). Effective June 1, 2019, admission to a SNF shall be covered up to 120 days of medically necessary care. Each day in a SNF counts as one-half benefit day of care.
(3) The hospital deductible amount imposed for noncompliance with pre- certification requirements will be $200. This deductible will be fully waived in instances where the medical record indicates that the patient was unable to make the call. In instances of non-compliance, a retroactive review of the necessity of services received shall be performed.
(4) Any day deemed inappropriate for an inpatient setting and/or not medically necessary after exhausting the internal and external appeal processes will be excluded from coverage under the Empire Plan.
(b) The Prospective Procedure Review Program (PPR) The Prospective Procedure Review Program (PPR) will screen for the medical necessity of certain listed diagnostic procedures which, based on Empire Plan experience, have been identified as potentially unnecessary or over-utilized. The Empire Plan Benefits Management Program Prospective Procedure Review requirement will include Magnetic Resonance Imaging (MRI). The list of procedures will undergo annual evaluation by the Medical Carrier.
(1) Effective April 1, 2010 a more managed approach to radiological procedures will be implemented. The Medical Component Insurer will improve the effectiveness of the benefit by re-enforcing credentialing requirements and “best practices” with Radiologists and other providers involved in providing radiological services to Empire Plan enrollees.
(2) The current PPR notification requirement for MRIs will expand to include CAT and PET scans, nuclear medicine and MRAs performed at the outpatient department of a hospital, a participating prov...
Benefits Management Program. The Benefits Management Program applies utilization man- agement and case management principles to assist Members and providers in identifying the most appropriate and cost- effective way to use the Benefits provided under this health plan. The Benefits Management Program includes prior authori- zation requirements for inpatient admissions, selected inpa- tient and outpatient services, office-administered injectable drugs, and home-infusion-administered drugs, as well as emergency admission notification, and inpatient utilization management. The program also includes Member services such as, discharge planning, case management and, pallia- tive care services. The following sections outline the requirements of the Ben- efits Management Program.
Benefits Management Program. The Benefits Management Program applies utilization management and case management principles to assist Members and providers in identifying the most appropriate and cost- effective way to use the Benefits provided under this health plan. The Benefits Management Program includes prior authorization requirements for inpatient admissions, selected inpatient and outpatient services, office-administered injectable drugs, and home-infusion-administered drugs, as well as emergency admission notification, and inpatient utilization management. The program also includes Member services such as, discharge planning, case management and, palliative care services. The “Prior Authorization List” is a list of medical services and drugs that require prior authorization. Members are encouraged to work with their providers to obtain prior authorization. Members and providers may call Customer Service at the number provided on the back page of this Evidence of Coverage to inquire about the need for prior authorization. Providers may also access the Prior Authorization List on the provider website. The following sections outline the Member’s responsibilities under the Benefits Management Program. The Benefits Management Program applies to all Members. used to authorize or deny health care services under the plan. Blue Shield has completed documentation of this process as required under Section 1363.5 of the California Health and Safety Code. The document describing Blue Shield’s Utilization Management Program is available online at xxx.xxxxxxxxxxxx.xxx or Members may call the Customer Service Department at the number provided on the back Prior authorization allows the Member and provider to verify with Blue Shield that (1) the proposed services are a Benefit of the Member’s plan, (2) the proposed services are Medically Necessary, and (3) the proposed setting is clinically appropriate. The prior authorization process also informs the Member and provider when Benefits are limited to services rendered by a Participating Provider (See the Summary of Benefits). The Member or provider should call Customer Service at the number provided on the back page of this Evidence of Coverage for prior authorization of non-emergency medical Hospital admissions and all medical services and drugs included in the Prior Authorization List (except for radiological and nuclear imaging procedures). Prior authorization for radiological and nuclear imaging procedures and Mental Health Services is addre...
Benefits Management Program. The Benefits Management Program applies utilization man- agement and case management principles to assist Members and providers in identifying the most appropriate and cost- effective way to use the Benefits provided under this health plan. The Benefits Management Program includes prior authoriza- tion requirements for inpatient admissions, selected inpatient and outpatient services, office-administered injectable drugs, and home-infusion-administered drugs, as well as emergency admission notification, and inpatient utilization management. The program also includes Member services such as, dis- charge planning, case management and, palliative care ser- vices. The following sections outline the requirements of the Bene- fits Management Program.
