PPO/DRP Medical Plan - Advocate Benefits - Advocate Health Care

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How to Use the Case Management Program Review When you or your physician contacts the PPO/ DRP administrator regarding a hospital admission or other service, you should provide: The name of the attending and/or admitting physician and his or her phone number The name of the hospital/location where the admission/service has been scheduled The scheduled admission/service date, and A preliminary diagnosis or reason for the admission/service.The PPO/DRP administrator will: Review the medical information provided and may follow up with your provider, and Determine whether the prescribed services or hospitalization is medically necessary. If the applicable health care services are not considered medically necessary, some days or the entire hospitalization will be denied. The claims administrator will notify you, the hospital and your physician of the decision and specify the date(s) for which benefits will not be paid. 18 What services does the PPO/DRP cover? For information about covered services and services that are not covered, you can call the PPO/DRP administrator at the number shown on your coverage ID card. A listing of services that are covered by the PPO/DRP is provided in Covered Services starting on page 19. Services Requiring Case Management Program Review Decisions about your course of treatment or whether you receive particular health services are between you and your physician. The claims administrator simply determines whether a proposed admission, continued hospitalization or other health care service is covered under your PPO/DRP coverage. Preadmission Review If your physician recommends a hospital admission for any reason—or admission to a skilled nursing facility or a program of home health care services—you must call the claims administrator in order to receive maximum benefits.
You must call to schedule a non-urgent admission at least 15 days in advance of your planned admission date. Preadmission review is not a guarantee of benefits. You must be a PPO/ DRP participant at the time services are provided, and the prescribed services must be covered by your PPO/DRP coverage. Emergency Admission Review In an emergency, you or someone on your behalf must call the PPO/DRP administrator within 48 hours or the next business day after the admission. You will not receive maximum benefits if the call is made later than the specified time period. Again, emergency admission review is not a guarantee of benefits. However, no pre-authorization is required for emergency room services. What happens if I decide to have medical services performed that the plan does not approve? Keep in mind that the PPO/DRP does not cover any services that are not medically necessary—and will not pay any related charges you incur. The fact that your physician may prescribe or recommend a particular service does not mean it is medically necessary or covered by your PPO/DRP coverage. Case Management Case Management service may be provided by the claims administrator. Participation in case management is voluntary. After Case Management has evaluated your case, you may be assigned a case manager. If your condition requires continued hospital care or care in another health care facility, the case manager may recommend an alternative treatment plan. The case manager will monitor your case for the duration of your condition. Alternative benefits will be covered as long as the PPO/DRP determines that the alternative services are medically necessary and cost-effective. Total payments for alternative services will not exceed the total benefit for which you would otherwise be entitled. 19 Covered Services The PPO/DRP covers the following expenses for hospital and other medical services and supplies for the treatment of an injury or disease. Only medically necessary treatments, services or supplies are covered. With the PPO/DRP, services are covered at the highest level of benefits when you use participating providers (see PPO/DRP At-A- Glance, page 6). In general, the plan pays 80% of negotiated charges for services received from participating providers and 60% of the reasonable and customary cost of services received from nonparticipating providers. Coverage for Advocate Hospital Services When you have the opportunity to use an Advocate hospital, Advocate will waive 10% of the cost of covered services; you will be responsible for 10%. This waiver will NOT apply to: Emergency room copayments or deductibles The charges of non-Advocate facilities—even if Advocate does not provide the service you need or if an Advocate facility is busy (“on bypass”) at the time the service is provided, and Charges for physician visits. Note: This waiver does not apply to the charges of an outside lab facility.
Page 1 and 2: PPO/DRP Medical Plan
Page 3 and 4: PPO/DRP Medical Plan If you are an
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Page 11 and 12: Incapacitated Dependents A child wi
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Page 15 and 16: PPO/DRP Benefits The PPO/DRP covera
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Page 21 and 22: Chiropractic Care The Plan will pay
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Page 25 and 26: Benefits for Newborns When you or a
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Page 31 and 32: Making a Claim Filing a Claim Any c
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Page 41 and 42: Reimbursement/Subrogation You and y
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PPO/DRP Medical Plan - Advocate Benefits - Advocate Health Care

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