Precertification.Β 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. 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): 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 memberβs 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. π π Oral evaluations, x-rays, Cleanings Sealants and fluoride, Space maintainers π Emergency palliative pain treatment π Amalgam restorations (fillings), Composite restoration (fillings) π Sedative fillings π Simple extractions, Removal of impacted teeth, General anesthesia π Root Canal Therapy, Therapeutic pulpotomy, Direct pulp capping π Scaling and root planing, Gingivectomy, Osseous surgery, Soft tissue grafts π Crowns, Removable complete and partial dentures π Bridge repair π Implants Not Covered Not Covered π Missing Teeth Covered Covered π π Examinations, Records Tooth guidance, Repositioning (straightening) of the teeth β’ Oral Evaluations. Limited to two per year. β’ Prophylaxis or Periodontal Maintenance Procedure. Limited to two treatments per year, singly or in combination. β’ Fluoride treatments. Limited to two per year for children up to age 19. β’ X-rays. Limited to one set of full-mouth x-rays or its equivalent once every five years. Periapical x-rays are limited to 4 films per year. β’ Bitewing X-rays. Limited to one set of up to 4 films twice per year to age 19 and once per year thereafter. β’ Sealants. Limited to children under 16 years of age for permanent unrestored first and second molars. Treatment is limited to two applications per tooth per lifetime.
Precertification.Β Members are encouraged to always obtain prior approval when using non-network providers. Precertification will help the
Precertification.Β 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.Β You need pre-approval from us for some covered services. Pre-approval is also called precertification. Your network physician is responsible for obtaining any necessary precertification before you get the care. Network providers cannot bill you if they fail to ask us for precertification. But if your physician requests precertification and we deny it, and you still choose to get the care, you will have to pay for it yourself. When you go to an out-of-network provider, you are responsible to get any required precertification from us. If you donβt precertify: β’ Your benefits may be reduced, or the plan may not pay. See your schedule of benefits for details. β’ You will be responsible for the unpaid bills. β’ Your additional out-of-pocket expenses will not count toward your deductible or maximum out-of- pocket limit, if you have any. Timeframes for precertification are listed below. For emergency services, precertification is not required, but you should notify us as shown. To obtain precertification, contact us. You, your physician or the facility must call us within these timelines: Non-emergency admission Call at least 14 days before the date you are scheduled to be admitted Emergency admission Call within 48 hours or as soon as reasonably possible after you have been admitted Urgent admission Call before you are scheduled to be admitted Outpatient non-emergency medical services Call at least 14 days before the care is provided, or the treatment or procedure is scheduled 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 injury. We will tell you and your physician in writing of the precertification decision, where required by state law. An approval is valid for 180 days as long as you remain enrolled in the plan. For an inpatient stay in a facility, we will tell you, your physician and the facility about your precertified length of stay. If your physician recommends that you stay longer, the extra days will need to be precertified. You, your physician, or the facility will need to call us as soon as reasonably possible, but no later than the final authorized day. We will tell you and your physician in writing of an approval or denial of the extra days. If you or your provider request precertification and we donβt approve coverage, we will tell you why and explain how you or your provider may request review of our decision. See the Complaints, claim decisions and appeal proce...
Precertification.Β 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.Β All non-emergency inpatient hospital admissions require Precertification as detailed in Section 2.3.1 of this Certificate.
Precertification.Β 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.Β 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 Memberβs coverage by the PPO or guarantee payment. Precertification is required even when the PPO is not the primary carrier.
Precertification.Β 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.Β A required review of a Health Care Service for a benefit coverage determination which must be done prior to the Health Care Service start date.
