Common use of Certification for Hospital Admissions Clause in Contracts

Certification for Hospital Admissions. If an individual becomes confined in a hospital as a full-time inpatient; and the insurance carrier has not certified that such confinement (or any day of such confinement) is necessary; then expenses incurred on any day not certified during the confinement will be paid as follows: 1. With respect to Major Medical Expense Coverage: a. With respect to expenses for hospital room and board: 1) If certification has been requested and denied, or if certification has not been requested and the confinement is not necessary, no benefits will be paid under this Major Medical Expense Coverage. 2) If certification has not been requested and the confinement is necessary, benefits will be paid under this Major Medical Expense Coverage at fifty percent (50%) after any deductible rather than at the coinsurance percentage. b. With respect to other Covered Medical Expenses, benefits will be paid under this Major Medical Expense Coverage at the coinsurance percentage after any deductible. 2. With respect to Basic Medical Expense Coverage: No benefits will be paid under Basic Medical Expense Coverage for expenses for hospital room and board. Benefits for all other expenses will be paid under Basic Medical Expense Coverage on the same terms as would apply in the absence of this Certification for Hospital Admissions. 3. Whether or not a day of confinement is certified, no benefit will be paid for expenses incurred on any day of confinement as a full-time inpatient if excluded by any other terms of this plan; except that, if certification has been given for a day of confinement, the exclusion of services and supplies because they are not necessary will not be applied to expenses for hospital room and board. 4. Certification of days of confinement can be obtained as follows: a. If the admission is a non-urgent admission, the employee must get the days certified by calling the insurance carrier at a toll-free number provided to each employee. This must be done at least fourteen (14) days before the date the individual is scheduled to be confined as a full-time inpatient. b. If the admission is an emergency or an urgent admission, the employee, the employee's physician or the hospital must get the days certified by calling the carrier at the toll-free number provided. This must be done before the start of a confinement as a full-time inpatient which requires an urgent admission; or not later than forty-eight (48) hours following the start of a confinement as a full-time inpatient which requires an emergency admission; unless it is not possible for the physician to request certification within that time. In that case, it must be done as soon as reasonably possible. c. In the event the confinement starts on a Friday or Saturday, the forty-eight (48) hours requirement will be extended to seventy-two (72) hours.

Certification for Hospital Admissions. If an individual becomes confined in a hospital as a full-time inpatient; and the insurance carrier has not certified that such confinement (or any day of such confinement) is necessary; then expenses incurred on any day not certified during the confinement will be paid as follows: 1. a. With respect to Major Medical Expense Coverage: a. 1) With respect to expenses for hospital room and board: 1a) If certification has been requested and denied, or if certification has not been requested and the confinement is not necessary, no benefits will be paid under this Major Medical Expense Coverage. 2b) If certification has not been requested and the confinement is necessary, benefits will be paid under this Major Medical Expense Coverage at fifty percent (50%) after any deductible rather than at the coinsurance percentage. b. 2) With respect to other Covered Medical Expenses, benefits will be paid under this Major Medical Expense Coverage at the coinsurance percentage after any deductible. 2. b. With respect to Basic Medical Expense Coverage: No benefits will be paid under Basic Medical Expense Coverage for expenses for hospital room and board. Benefits for all other expenses will be paid under Basic Medical Expense Coverage on the same terms as would apply in the absence of this Certification for Hospital Admissions. 3. c. Whether or not a day of confinement is certified, no benefit will be paid for expenses incurred on any day of confinement as a full-time inpatient if excluded by any other terms of this plan; except that, if certification has been given for a day of confinement, the exclusion of services and supplies because they are not necessary will not be applied to expenses for hospital room and board. 4. d. Certification of days of confinement can be obtained as follows: a. (1) If the admission is a non-urgent admission, the employee must get the days certified by calling the insurance carrier at a toll-free number provided to each employee. This must be done at least fourteen (14) days before the date the individual is scheduled to be confined as a full-time inpatient. b. (2) If the admission is an emergency or an urgent admission, the employee, the employee's physician or the hospital must get the days certified by calling the carrier at the toll-free number provided. This must be done before the start of a confinement as a full-time inpatient which requires an urgent admission; or not later than forty-eight (48) hours following the start of a confinement as a full-time inpatient which requires an emergency admission; unless it is not possible for the physician to request certification within that time. In that case, it must be done as soon as reasonably possible. c. (3) In the event the confinement starts on a Friday or Saturday, the forty-eight (48) hours requirement will be extended to seventy-two (72) hours.two