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Pre-Authorization6. A letter of medical necessity;7. A written treatment plan; and8. Any other information deemed necessary to evaluate the pre-authorization request.Upon receipt of all required information, the Plan will provide a written response to the written request forpre-authorization of services.THE BENEFITS QUOTED ARE NOT A GUARANTEE OF PAYMENT. FINAL DETERMINATION AS TOBENEFITS PAID WILL BE MADE AT THE TIME THE CLAIM IS SUBMITTED FOR PAYMENT WITHREVIEW OF NECESSARY MEDICAL RECORDS AND OTHER INFORMATION.Western Montana Providence Health & Services - SPD 32Group #2000204 - January 1, 2011
<strong>HOSPITAL</strong> ADMISSION CERTIFICATIONPre-certification is strongly recommended on all Inpatient hospital admissions other than urgent care.Pre-certification, Plan notification and case management are designed to:1. Provide information regarding coverage before you receive treatment, services, or supplies;2. Provide information about benefits regarding proposed procedures or alternate treatment plans;3. Assist in determining out-of-pocket expenses and identify possible ways to reduce them;4. Help avoid reductions in benefits which may occur if the services are not medically necessary orthe setting is not appropriate; and5. If appropriate, assign a case manager to work with you and your providers to design a treatmentplan.A benefit determination on a claim will be rendered only after the claim has been submitted to adjudicatewhether it is eligible for coverage under the terms and conditions of the Plan. If it is determined not to beeligible, the Covered Person will be responsible to pay for all charges that are determined to be ineligible.Therefore, although not required, pre-certification and plan notification of emergency admissions isstrongly recommended to obtain coverage information prior to incurring the charges.PRE-ADMISSION CERTIFICATION REVIEWThe Plan recommends that prior to admission for any non-emergency illness or injury , and within seventytwo(72) hours after admission for any emergency Illness or Injury, the Covered Person or the CoveredPerson's attending physician call the designated utilization management company, retained by the PlanSponsor in connection with this Plan, for a pre-admission certification review.To pre-certify, call the utilization management company at 1-800-342-6510 for pre-admissioncertification review.Most certifications occur over the phone. Once a final decision is made regarding the request forcertification, a notice of pre-certification will be sent to the physician, to the Covered Person, to the PlanSupervisor and to the hospital. This notice is not required, and therefore, cannot be appealed.NOTE: PRE-CERTIFICATION OF BENEFITS IS NOT A GUARANTEE OF PAYMENT OF THECLAIM(S). ELIGIBILITY FOR CLAIM PAYMENTS IS DETERMINED AT THE TIME CLAIMS AREADJUDICATED SINCE THE AMOUNT OF BENEFIT COVERAGE, IF ANY, IS SUBJECT TO ALL PLANPROVISIONS INCLUDING, BUT NOT LIMITED TO, MEDICAL NECESSITY, PATIENT ELIGIBILITY,DEDUCTIBLES, CO-PAYMENTS AND ANY PLAN LIMITATIONS OR MAXIMUMS IN EFFECT WHENTHE SERVICES ARE PROVIDED. PROVIDERS AND COVERED PERSONS ARE INFORMED AT THETIME CLAIMS ARE PRE-CERTIFIED THAT PRE-CERTIFICATION OF A COURSE OF TREATMENTBY THE PLAN DOES NOT GUARANTEE PAYMENT OF CLAIMS FOR THE SAME.Western Montana Providence Health & Services - SPD 33Group #2000204 - January 1, 2011
Page 2: Western Montana Providence Health &
Page 9 and 10: SCHEDULE OF MEDICAL BENEFITS - PROV
Page 11 and 12: Schedule of Medical Benefits - Prov
Page 13 and 14: SCHEDULE OF MEDICAL BENEFITS - PROV
Page 16 and 17: Schedule of Medical Benefits - Prov
Page 18 and 19: Pharmacy BenefitWhen Primary Covera
Page 20 and 21: Pharmacy BenefitPRIMARY COVERAGE UN
Page 22 and 23: MEDICAL BENEFIT DETERMINATION REQUI
Page 24 and 25: Medical Benefit Determination Requi
Page 26 and 27: Medical Benefits5. Charges made by
Page 28 and 29: Medical Benefits15. Charges for dru
Page 30 and 31: Medical BenefitsGENETIC AND INFERTI
Page 32 and 33: Medical BenefitsPREVENTIVE CARE“P
Page 34 and 35: Medical Benefits3. Services provide
Page 36 and 37: Medical BenefitsBody Mass Index (BM
Page 40 and 41: Hospital Admission CertificationCON
Page 42 and 43: Medical Benefit Exclusions10. Charg
Page 44 and 45: GENERAL PLAN EXCLUSIONS AND LIMITAT
Page 46 and 47: General Plan Exclusions and Limitat
Page 48 and 49: Coordination of Benefits“Plan”
Page 50 and 51: Coordination of Benefits3. For Cove
Page 52 and 53: Procedures for Claiming Benefits1.
Page 54 and 55: Procedures for Claiming Benefits2.
Page 56 and 57: Eligibility ProvisionsD. The ABR is
Page 58 and 59: EFFECTIVE DATE OF COVERAGEAll cover
Page 60 and 61: Effective Date of CoverageD. Placem
Page 62 and 63: QUALIFIED MEDICAL CHILD SUPPORT ORD
Page 64 and 65: FAMILY AND MEDICAL LEAVE ACT OF 199
Page 66 and 67: Family and Medical Leave ActENFORCE
Page 68 and 69: Termination of Coverage7. The date
Page 70 and 71: CONTINUATION COVERAGE AFTER TERMINA
Page 72 and 73: Continued Coverage After Terminatio
Page 74: Continued Coverage After Terminatio
Page 77 and 78: COVERAGE FOR A MILITARY RESERVISTTo
Page 80 and 81: Recovery/Reimbursement/SubrogationT
Page 82 and 83: PLAN ADMINISTRATIONPURPOSEThe purpo
Page 84 and 85: CREDITABLE COVERAGE PROCEDURESCERTI
Page 86 and 87: General ProvisionsWORKERS' COMPENSA
Page 88 and 89:
General DefinitionsBENEFIT PERCENTA
Page 90 and 91:
General DefinitionsCUSTODIAL CARE
Page 92 and 93:
General Definitions“Reliable Evid
Page 94 and 95:
General DefinitionsLATE ENROLLMENT
Page 96 and 97:
General Definitions9. Are approved
Page 98 and 99:
General DefinitionsPREVENTIVE CARE
Page 100 and 101:
General DefinitionsTOTAL DISABILITY
Page 102 and 103:
ERISA Statement of RightsIf you hav
Page 104 and 105:
HIPAA Privacy and Security Standard
Page 106:
Plan Summary9. IDENTIFICATION NUMBE
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