SSMC Employee Health Benefit Plan
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emergency admission. You must call:
a. At least 7 days before an admission or when the Physician decides that you or one of your Dependents
requires admission to a Hospital, Birth Center, Skilled Nursing Facility, Psychiatric Facility, or any
other Inpatient facility.
b. Within 48 hours after an emergency or urgent admission.
c. Within 24 hours for Inpatient Care that is more than the first 48 hours after a normal delivery of
newborn or 96 hours after a cesarean section. For all other maternity admissions, follow instructions
shown in "a" or "b" above.
d. Within 24 hours for Inpatient newborn care that is more than the first 96 hours after birth.
e. Before home care begins when the Physician orders Home Health Care Agency services instead of
Inpatient Care.
Please Note
Others may initiate the required phone call, such as family member, doctor or Hospital personnel. However, it is
your responsibility to confirm that the call was made. This review applies to any Hospital or other covered facility in
the USA, including Hawaii and Alaska.
2. Noncompliance Benefit Reduction. If you fail to comply with the phone call requirements of this review,
you will be subject to the following benefit reduction:
$200.00 reduction of available benefits for Hospital or other facility covered services. This reduction
is in addition to any Plan Deductible or Copayments and does not count toward any Deductible or
Percentage Copayment maximum.
Informing the Hospital, facility or your doctor of the pre-admission review requirement does not eliminate
this benefit reduction if the phone call is not made. If you fail to make the pre-admission phone call, and it
is decided at the time of claim submission that the Inpatient admission was not Medically Necessary,
benefits could be denied.
3. Plan Notification. A written or oral Plan Notification of the benefit determination, whether adverse or not,
will be sent to you, the Physician and the facility as follows:
·
For Urgent Care, within 72 hours after the urgent care claim for benefits is received.
·
For Concurrent Urgent Care, within 24 hours after request to extend course of treatment involving
urgent care (when request is made for care at least 24 hours prior to expiration of the current prescribed
period of time or number of treatments).
·
For Non-Urgent Care, within 48 hours (two business days) after the Medical Services Department
completes their review, but no later than 15 days after the non-urgent claim for benefits is received.
Please Note
Pre-admission certification does not guarantee benefits to you or your Provider and will not result in payment of benefits
that would not otherwise be payable. It is a preliminary review of the Inpatient setting based entirely on the limited
information provided to the POMCO Medical Services Department at the time of the pre-admission review. If medical
documentation at the time services are rendered is other than that provided during this initial review, and it is decided
according to Plan provisions and limitations that the Hospitalization was not Medically Necessary, or otherwise excluded
under the Plan, benefits may be denied.
C. Concurrent Review
If you or your Eligible Dependent is confined in a Hospital or other approved facility, the POMCO Medical
Services Department's professional staff will monitor the patient's progress, severity of Illness, and intensity of
services via their concurrent review procedures. You, the Physician and the facility will receive Plan
Notification of the benefit determination within 24 hours after request to extend course of treatment involving
urgent care (when request is made for care at least 24 hours prior to expiration of the current prescribed period
of time or number of treatment). For non-urgent care, Plan notice will be sent within 48 hours (two business
days).
