SSMC Employee Health Benefit Plan
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SECTION III - BENEFIT MANAGEMENT PROGRAM
All Plan claim and appeal procedures under this section will comply with the minimum requirements set
forth by the Department of Labor Regulations established in accordance with the Employee Retirement
Income Security Act of 1974 (ERISA) applicable to this Plan as of January 1, 2003.
The Benefit Management Program is designed to answer questions and explore your choices when you or your
Dependents face Hospitalization, Surgery or extensive medical care. The Benefit Management Program
consists of Pre-admission Review, Concurrent Inpatient Review and Medical Case Management. The Benefit
Management Program applies to all participants whose primary coverage is this Plan. It does not apply if your
primary coverage is Medicare or another group health benefit plan. This Benefit Management Program is
administered by:
POMCO
Medical Services Department
P.O. Box 6329
Syracuse, NY 13217
Phone: Toll-free # 1-800-501-9536
If you wish to talk to the POMCO nurses, you must call between 8:00 A.M. and 4:30 P.M. (ET) on normal
business days. Otherwise, provide complete information as requested by voice mail message. This is a 24-hour
service. When calling POMCO be prepared to supply the following information:
·
Identify Name of Plan SSMC Employee Health Benefits Plan
·
Enrollee's Social Security Number
·
Patient's Name and Address
·
Physician's Name, Address and Phone Number
·
Name of Hospital
·
Anticipated Date of Admission or Date Admitted
A. Notice for Federal Newborns' and Mothers' Act
Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any
Hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours
following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law
generally does not prohibit the mother's or newborn's attending Physician, after consulting with the mother,
from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case,
plans and insurers may not, under federal law, require that a Provider obtain authorization for prescribing a
length of stay that is not in excess of 48 hours (or 96 hours).
B. Pre-admission Review
The pre-admission review is a preliminary evaluation by the POMCO professional staff to decide whether an
Inpatient setting is Medically Necessary according to the provisions of the Plan. If the Medical Necessity of the
Inpatient setting is established based on available information, the admission will be pre-certified. If the
Medical Necessity is not established based on available information, the Inpatient admission will not be pre-
certified. Written notification of the POMCO Medical Services Department's decision will be mailed to you,
your doctor and the facility within 48 hours (two business days) after their review.
1. Participant Telephone Requirement. The purpose of the participant telephone call is to initiate the pre-
admission review and to advise the patient whether coverage is available. If this Plan is primary, you must
call the POMCO Medical Services Department before a scheduled admission to any Inpatient facility or
before Home Health Care Agency services are rendered. You must call within 48 hours after an urgent or
