Huntington Ingalls Newport News Anthem Key ... - Benefits Connect

How your health plan works - 11
• the availability of, and contact information for, the U.S. Department of Labor’s Employee Benefits
Security Administration that may assist you with the internal or external appeals process.
If all or part of a pre-service or urgent care claim was not covered, you have a right to see, upon
request and at no charge, any rule, guideline, protocol or criterion that your health plan relied upon in
making the coverage decision. If a coverage decision was based on medical necessity or the
experimental nature of the care, you are entitled to receive, upon request and at no charge, the
explanation of the scientific or clinical basis for the decision as it relates to your medical condition.
Approvals of care involving an ongoing course of treatment
Network providers must follow certain procedures to ensure that if a previously approved course of
treatment needs to be extended, the extension is requested in time to minimize disruption of needed
services. If you are receiving care from a non-network provider and need to receive an extension of a
previously approved course of treatment, you will be required to ask for the extension. You should
request the extension at least 24 hours prior to the end of the authorized time frame to avoid
disruption of care or services. We will notify you of our coverage decision within 24 hours of your
request.
In an emergency or if specialty care is not reasonably available in the network
If you have an emergency medical condition, go to the nearest appropriate provider or medical facility. If
the provider or facility is not in the network, you or your network physician can call Anthem to have
the out-of-network services authorized for the highest level of benefits.
If specialty care is required and it’s not available from a provider within the network, your network
provider can call Anthem in advance of your receiving care to have the out-of-network services
authorized for the highest level of benefits.
Hospital Admission Review
All hospital stays, skilled nursing home stays, or treatment in partial day programs should be approved
before each admission. The exception to this is maternity admissions as specified in the maternity
section of this booklet. If you are admitted to the hospital as a result of an emergency medical condition,
your hospital stay should be reviewed by Anthem within 48 hours of admission. The emergency room
doctor, a relative, or a friend can call for Hospital Admission Review. Network providers and facilities
handle Hospital Admission Review for you. You must initiate the Hospital Admission Review process
for out-of-network services. If you fail to obtain approval for an inpatient stay, and the stay is later
determined not to be medically necessary, you may have to pay the entire hospital bill in addition to
any charges for services provided while you were an inpatient. Strict adherence to this procedure may
not be required for services that arise over the weekend.