Common use of Benefits Management Program Clause in Contracts

Benefits Management Program. (a) Pre-certification shall be required for all elective inpatient confinements and prior to certain specified medical procedures to provide an opportunity for a review of diagnostic procedures for appropriateness of setting and effectiveness of treatment alternatives. (1) A call to the Benefits Management Program will be required within 48 hours of admission for all emergency or urgent admissions to permit early identification of potential “case management” situations. (2) The hospital deductible amount imposed for noncompliance with pre- certification requirements will be $200. This deductible will be fully waived in instances where the medical record indicates that the patient was unable to make the call. In instances of non-compliance, a retroactive review of the necessity of services received shall be performed. (3) Any day deemed inappropriate for an inpatient setting and/or not medically necessary after exhausting the internal and external appeal processes will be excluded from coverage under the Empire Plan. (4) Pre-certification will be required prior to maternity admissions in order to highlight appropriate prenatal services and reduce costly and traumatic birthing complications. Effective January 1, 2020, the requirement for pre- certification of maternity admissions for the birth of a child shall be eliminated. Pre-certification is still required for admissions to the hospital related to pregnancy complications prior to birth, and if the mother and/or the newborn are hospitalized for more than 48 hours for a vaginal delivery or 96 hours for a cesarean delivery. (5) Pre-certification will be required prior to an admission to a Skilled Nursing Facility (SNF). Admission to a skilled nursing facility shall be covered up to 120 days of medically necessary care. Each day in a skilled nursing facility counts as one-half benefit day of care. (b) The Prospective Procedure Review Program (PPR) will screen for the medical necessity of certain listed diagnostic procedures which, based on Empire Plan experience, have been identified as potentially unnecessary or over-utilized. (1) The Empire Plan Benefits Management Program Prospective Procedure Review requirement will include Magnetic Resonance Imaging (MRI). The current PPR notification requirement for MRIs will expand to include CAT and PET scans, nuclear medicine and MRAs performed at the outpatient department of a hospital, a participating provider office or a free-standing facility. The list of procedures will undergo annual evaluation by the Medical Carrier. (2) The Medical Component Insurer will improve the effectiveness of the benefit by re-enforcing credentialing requirements and “best practices” with Radiologists and other providers involved in providing radiological services to Empire Plan enrollees. (3) Enrollees will be required to call the Benefits Management Program for Pre-certification when a listed procedure is recommended. Enrollees will be requested to call two weeks before the date of the procedure. (4) Current co-insurance levels will apply for failure to comply with the requirements of the Prospective Procedure Review Program.

Benefits Management Program. (a) Pre-certification shall The Benefits Management Program will continue. Precertification will be required for all elective inpatient confinements except maternity admissions as described below and prior to certain specified surgical or medical procedures to procedures, regardless of proposed inpatient or outpatient setting. 1. To provide an opportunity for a review of surgical and diagnostic procedures for appropriateness of setting and effectiveness of treatment alternativesalternative, precertification will be required for all inpatient elective admissions. (1) 2. Precertification will not be required prior to maternity admissions Precertification is required for inpatient admissions during pregnancy for reasons other than labor and delivery. 3. A call to the Benefits Management Program will be required within 48 forty-eight (48) hours of admission for all emergency or urgent admissions to permit early identification of potential “case management” situations. (2) 4. Precertification will be required prior to an admission to a skilled nursing facility. 5. The hospital deductible amount imposed for noncompliance non-compliance with pre- certification Program requirements will be $200. This deductible will be fully waived in instances where the medical record indicates that the patient was unable to make the call. In instances of non-compliance, a retroactive review of the necessity of services received shall be performed. (3) 6. Any day deemed inappropriate for an inpatient setting and/or not medically necessary after exhausting the internal and external appeal processes will be excluded from coverage under the Empire Plan. (4) Pre-certification will be required prior to maternity admissions in order to highlight appropriate prenatal services and reduce costly and traumatic birthing complications7. Effective January 1, 2020, the requirement for pre- certification of maternity admissions for the birth of a child shall be eliminated. Pre-certification is still required for admissions to the hospital related to pregnancy complications prior to birth, and if the mother and/or the newborn are hospitalized for more than 48 hours for a vaginal delivery or 96 hours for a cesarean delivery.The Prospective Procedure Review Program (5) Pre-certification will be required prior to an admission to a Skilled Nursing Facility (SNF). Admission to a skilled nursing facility shall be covered up to 120 days of medically necessary care. Each day in a skilled nursing facility counts as one-half benefit day of care. (ba) The Prospective Procedure Review Program (PPR) will screen for the medical necessity of certain listed specified surgical or diagnostic procedures whichthat, based on Empire Plan experience, have been identified as potentially unnecessary or over-utilized. (overutilized. Effective July 1) The Empire Plan Benefits Management Program Prospective Procedure Review requirement will include , 2008, in addition to Magnetic Resonance Imaging (MRI). The current PPR notification requirement for MRIs will expand to include , Computerized Axial Tomography (CAT and scans), Positron Emission Tomography (PET scans), nuclear medicine Magnetic Resonance Angiography (MRAs) and MRAs performed at Nuclear Medicine Examinations will be added to the outpatient department of a hospital, a participating provider office or a free-standing facility. The list of procedures will undergo annual evaluation by the Medical CarrierProspective Procedure Review Program. (2) The Medical Component Insurer will improve the effectiveness of the benefit by re-enforcing credentialing requirements and “best practices” with Radiologists and other providers involved in providing radiological services to Empire Plan enrollees. (3b) Enrollees will be required to call the Benefits Management Program for Pre-certification precertification when a listed procedure subject to prospective review is recommended, regardless of setting. Enrollees will be requested to call two weeks before the date of the procedure. (4c) Current co-insurance levels The Empire Plan’s Prospective Procedure Review penalties will apply for failure to comply with the requirements of the Prospective Procedure Review ProgramProgram regardless of whether the expense is an outpatient hospital or medical program expense. 8. The Voluntary Medical Case Management component of the Empire Plan’s Benefits Management Program will continue. This voluntary program will review cases of illness or injury, provide patients an opportunity for flexibility in Plan benefits, maximize rate of recovery, and maintain quality of care.

Benefits Management Program. (a) Pre-certification shall be required for all elective inpatient confinements and prior to certain specified medical procedures to provide an opportunity for a review of diagnostic procedures for appropriateness of setting and effectiveness of treatment alternatives. Pre-certification will be required prior to maternity admissions in order to highlight appropriate prenatal services and reduce costly and traumatic birthing complications. (1) A call to the Benefits Management Program will be required within 48 hours of admission for all emergency or urgent admissions to permit early identification of potential “"case management” " situations. (2) Precertification will be required prior to an admission to a Skilled Nursing Facility (SNF). Effective June 1, 2019, admission to a SNF shall be covered up to 120 days of medically necessary care. Each day in a SNF counts as one-half benefit day of care. (3) The hospital deductible amount imposed for noncompliance with pre- certification requirements will be $200. This deductible will be fully waived in instances where the medical record indicates that the patient was unable to make the call. In instances of non-compliance, a retroactive review of the necessity of services received shall be performed. (34) Any day deemed inappropriate for an inpatient setting and/or not medically necessary after exhausting the internal and external appeal processes will be excluded from coverage under the Empire Plan. (4b) Pre-certification will be required prior to maternity admissions in order to highlight appropriate prenatal services and reduce costly and traumatic birthing complications. Effective January 1, 2020, the requirement for pre- certification of maternity admissions for the birth of a child shall be eliminated. Pre-certification is still required for admissions to the hospital related to pregnancy complications prior to birth, and if the mother and/or the newborn are hospitalized for more than 48 hours for a vaginal delivery or 96 hours for a cesarean delivery. The Prospective Procedure Review Program (5) Pre-certification will be required prior to an admission to a Skilled Nursing Facility (SNF). Admission to a skilled nursing facility shall be covered up to 120 days of medically necessary care. Each day in a skilled nursing facility counts as one-half benefit day of care. (bPPR) The Prospective Procedure Review Program (PPR) will screen for the medical necessity of certain listed diagnostic procedures which, based on Empire Plan experience, have been identified as potentially unnecessary or over-utilized. (1) . The Empire Plan Benefits Management Program Prospective Procedure Review requirement will include Magnetic Resonance Imaging (MRI). The list of procedures will undergo annual evaluation by the Medical Carrier. (1) Effective April 1, 2010 a more managed approach to radiological procedures will be implemented. The Medical Component Insurer will improve the effectiveness of the benefit by re-enforcing credentialing requirements and “best practices” with Radiologists and other providers involved in providing radiological services to Empire Plan enrollees. (2) The current PPR notification requirement for MRIs will expand to include CAT and PET scans, nuclear medicine and MRAs performed at the outpatient department of a hospital, a participating provider office or a free-standing facility. The list of procedures will undergo annual evaluation by the Medical Carrier. (2) The Medical Component Insurer will improve the effectiveness of the benefit by re-enforcing credentialing requirements and “best practices” with Radiologists and other providers involved in providing radiological services to Empire Plan enrollees. (3) Enrollees will be required to call the Benefits Management Program for Pre-certification when a listed procedure is recommended. Enrollees will be requested to call two weeks before the date of the procedure. (4) Current co-insurance levels will apply for failure to comply with the requirements of the Prospective Procedure Review Program.