The eligibility and enrollment rules for the U

Retiree Health Care SPD Effective January 1, 2012
Preadmission Notification and Prior Authorization for BCBS of MN-
Administered Benefits
Preadmission Notification*
BCBS needs to be notified of planned (non-emergency) admissions before you or a covered
dependent is admitted. This process is known as “preadmission notification.” Verify with your
provider if this is a service they will perform for you or if you will need to complete the
preadmission notification. Ultimately, you are responsible for ensuring preadmission notification
has been made to BCBS.
Preadmission notification applies for the following facilities**
1. All hospital admissions;
2. Rehabilitation facility admissions;
3. Long-term acute care (LTAC) admissions;
4. Residential mental health and substance abuse treatment facilities; and
5. Outpatient mental health and substance abuse treatment facilities providing partial
hospitalization.
This list may not be exhaustive and is subject to change.
* Final payment of benefits is based on the coverage you have on the day services are received, whether lifetime
benefit maximums have been exceeded, and whether the service authorized is the service billed. Any decision to
undergo treatment rests with the patient, subscriber, and the provider. If you want to verify whether a service is
covered, you must call BCBS.
** If Medicare is the primary payer for you or a covered dependent, “preadmission notification” does not apply,
except for admissions for Transplants and Bariatric Surgery.
Preadmission Notification Process
In order to avoid liability for charges that are not considered medically necessary, notification is
recommended for admissions to a participating facility. However, notification is required for
admissions to a non-participating facility for the Comprehensive option or for admissions to an
out-of-network facility for the Early Retiree Medical option. If BCBS is not notified before you
or a covered dependent is admitted, any benefit payment payable under the plan is reduced. This
reduction is called a Non-Notification Penalty. A Non-Notification Penalty of $300 per
admission (or the amount of the covered expense, if less than $300), will apply. The Non-
Notification Penalty does not apply to your deductible or out-of-pocket limits. If notification is
not provided (whether recommended or required), and it’s determined at the point the claim is
processed that services were not medically necessary, you are liable for all of the charges.
To provide preadmission notification, call BCBS at least five working days before a planned
admission. The number to call is on the back of your BCBS ID card. After you call, a patient
care coordinator will determine if the admission is medically necessary and consult with your
admitting physician regarding your care. In addition to preadmission notification, you should
also obtain prior authorization for any services related to the admission for which prior
authorization is recommended. See “Prior Authorization” later in this section.
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