Precertification. Members are encouraged to always obtain prior approval when using non-network providers. Precertification will help avoid any unnecessary reduction in benefits for non-covered or non-medically necessary services. Pre-existing Exclusion Period: We will not provide benefits for services, supplies or charges for any pre-existing condition for the time period specified below (subject to HIPAA portability requirements and excludes members under age 19): 12 months after the member’s enrollment date A pre-existing condition is a condition (mental or physical) which was present and for which medical advice, diagnosis, care or treatment was recommended or received within the 6-month period ending on the member’s enrollment date. Pregnancy and domestic violence are not considered a pre-existing condition. Genetic information may not be used as a condition in the absence of a diagnosis. Benefit Summary – Dental Blue Access 100/200/300 Annual Deductible Individual/Family Combined In and Out of Network Annual Maximum $50 Individual / $100 Family $ 1,500 Services PPO Dentists (In-network) Non-PPO (Out-of-network) Diagnostic and preventive NCS/No deductible NCS/No deductible 🞈 🞈 Oral evaluations, x-rays, Cleanings Sealants and fluoride, Space maintainers Minor restorative 30% after deductible 30% after deductible 🞈 Emergency palliative pain treatment 🞈 Amalgam restorations (fillings), Composite restoration (fillings) 🞈 Sedative fillings Oral surgery 30% after deductible 30% after deductible 🞈 Simple extractions, Removal of impacted teeth, General anesthesia Endodontic services 30% after deductible 30% after deductible 🞈 Root Canal Therapy, Therapeutic pulpotomy, Direct pulp capping Periodontal services 30% after deductible 30% after deductible 🞈 Scaling and root planing, Gingivectomy, Osseous surgery, Soft tissue grafts Prosthodontic Services 40% after deductible 40% after deductible 🞈 Crowns, Removable complete and partial dentures 🞈 Bridge repair 🞈 Implants Not Covered Not Covered 🞈 Missing Teeth Covered Covered Orthodontic Services 40%/No deductible 40%/No deductible 🞈 🞈 Examinations, Records Tooth guidance, Repositioning (straightening) of the teeth Orthodontic Maximum $1,500 Orthodontic Age Limit Adult & Child to Age 19 Limitations — Below is a partial listing of some of the limitations. Please see Certificate for full list: • Oral Evaluations. Limited to two per year. • Prophylaxis or Periodontal Maintenance Procedure. Limited to two treatments per ye...
Precertification. I understand that KFMC will assist with insurance precertification requirements which are the responsibility of the policyholder and/or physician, but will not assume responsibility for precertification or any impact which it may have on insurance payment.
Precertification. Members are encouraged to always obtain prior approval when using non-network providers. Precertification will help the member know if the services are considered not medically necessary. Pre-existing Exclusion Period: none This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits. Exceptions Approved ▪ Plan would provide coverage for sexual dysfunction (Medical & Rx). ▪ Plan would cover surgical treatment of morbid obesity (Medical & Rx). ▪ Plan would cover most procedures and tests connected to diagnosing and treating infertility as long as those tests and procedures are not specifically related to the preparation and actual fertilization process. Benefits will be payable same as any illness. Examples of procedures and supplies which are not covered are: in-vitro fertilization, embryo implantation, gamete intra-fallopian transfer (GIFT), zygote intra-fallopian transfer (ZIFT), artificial insemination, fertility testing, fertility drugs, and reversal of sterilization. ▪ 4th quarter deductible carryover. ▪ Plan to cover elastic (compression) stockings.
Precertification. You need pre-approval from us for some eligible health services. Pre-approval is also called precertification. In-network: Your physician or PCP is responsible for obtaining any necessary precertification before you get the care. If your physician or PCP doesn't get a required precertification, we won't pay the provider who gives you the care. You won't have to pay either if your physician or PCP fails to ask us for precertification. If your physician or PCP requests precertification and we refuse it, you can still get the care but the policy won’t pay for it. You will find details on requirements in the What the policy pays and what you pay - Important note – when you pay all section. Out-of-network: When you go to an out-of-network provider, you are responsible to obtain precertification from us for any services and supplies on the precertification list. If you do not precertify, your benefits may be reduced, or the policy may not pay. See your schedule of benefits for this information. The list of services and supplies that require precertification appears later in this section. Also, for any precertification benefit reduction that is applied, see the schedule of benefits Precertification benefit reduction section. You should get precertification within the timeframes listed below. To obtain precertification, call us at the telephone number listed on your ID card. This call must be made: You, your physician or the facility will: For non-emergency admissions Call and request precertification at least 14 days before the date you are scheduled to be admitted. For an emergency medical condition Call prior to the outpatient care, treatment or procedure or as soon as reasonably possible. For an emergency admission Call within 48 hours or as soon as reasonably possible after you have been admitted. For an urgent admission Call before you are scheduled to be admitted. An urgent admission is a hospital admission by a physician due to the onset of or change in an illness, the diagnosis of an illness, or an injury. For outpatient non-emergency medical services requiring precertification Call at least 14 days before the outpatient care is provided, or the treatment or procedure is scheduled. We will tell you and your physician in writing of the precertification decision, where required by state law. If your precertified services are approved, the approval is valid for 180 days as long as you remain insured under the policy. When you have an inpatient stay in a faci...
Precertification. The purpose of Precertification is to encourage and facilitate use of the most appropriate level of care for Medically Necessary services utilizing industry accepted criteria for severity of illness and intensity of service. Precertification does not verify a Member’s coverage by the PPO or guarantee payment. Precertification is required even when the PPO is not the primary carrier.
Precertification. All non-emergency inpatient hospital admissions require Precertification as detailed in Section 2.3.1 of this Certificate.
Precertification. All transplant surgery and transplant-related services (with the exception of corneal transplants) require Precertification by the PPO. Medical criteria for any approved transplants will be applied and each potential transplant must be appropriate for the medical condition for which the transplant is proposed. Corneal transplants are covered when Medically Necessary and performed through a Preferred Provider.
Precertification. A pregnancy must be pre-certified within the first two (2) trimesters to be eligible for parental leave. The employee requesting leave must submit to the employing unit a Request for parental Leave form and a statement from a health care provider that confirms that the pregnancy is within the first two trimesters, the estimated date of birth, and that regular prenatal care is being provided. The unit head or a designee must sign the Request for Parental Leave form and forward it, along with the pre-certification, to the appropriate human resource office. In the case of adoption, a Request for Parental Leave form and evidence that either the initial placement or the legal adoption is imminent should be provided to the employing unit. The unit head or a designee must sign and forward the Request for Parental Leave form, along with evidence of adoption to the appropriate human resource office.
Precertification. I understand that Orthopaedic and Sports Medicine Center will assist with insurance precertification requirements which are the responsibility of the policyholder and/or physician but will not assume responsibility for precertification or any impact which it may have on insurance payment.
Precertification. The Plan has designated certain Covered Services which require “Precertification” in order for you to receive the maximum Benefits possible under the Contract. To request Precertification, you or your Provider may simply call the telephone number shown on your identification card. For an Inpatient facility stay, you must request Precertification from the Plan before your scheduled admission. The Plan will consult with your Physician, Hospital, or other facility to determine if Inpatient level of care is required for your illness or injury. The Plan may decide that the treatment you need could be provided just as effectively in a less expensive setting (such as the Outpatient department of the Hospital, an Ambulatory Surgical Facility, or the Physician’s office). If the Plan determines that your treatment does not require Inpatient care, you and your Provider will be notified of that decision. If you proceed with an Inpatient stay without the Plan’s approval, or if you do not ask the Plan for Precertification, your Benefits under this Contract will be reduced by 20% for that admission, provided the Plan determines that Benefits are payable upon receipt of a claim. This reduction applies in addition to any penalties associated with your use of an Out-of-Network Provider.
