SSMC Employee Health Benefit Plan
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D. Medical Case Management
If you or your Eligible Dependent requires intensive care or home care, the POMCO Medical Services
professional staff will help you to make decisions regarding treatment plans and facilities for coordinating
medical services and Plan benefits. This can be initiated by you or by the POMCO professional staff.
Participation is voluntary and can be ended anytime. Coordination of services could include alternate treatment
or an alternate facility. The POMCO professional staff will work with you and your doctor to facilitate services
covered by the Plan. You may contact the POMCO Medical Services Department by phoning their toll-free
number. 1-800-501-9536.
E. Right to Appeal
If you or the attending Physician disagrees with any determinations made by the POMCO Medical Services Department,
an appeal process gives you the opportunity to have your case reconsidered. For details of appeal procedures, please
refer to Section VIIIClaim Submission and Review Procedures under Plan Determination Notices and Claimant
Appeals.
1. Expedited Appeal for Urgent Pre-Service Care or for Concurrent Care. You or your Dependent, the
attending Physician or other ordering Provider may request a written or oral appeal when an adverse
decision by the POMCO Medical Service Department warrants an immediate appeal for urgent pre-service
or urgent concurrent care. For details of appeal procedures, please refer to Section VIII-Claim Submission
and Review Procedures under Plan Determination Notices and Claimant Appeals.
2. Standard Appeal for Non-Urgent Pre-Service Care. You or your Dependent, attending Physician or
other Provider may request in writing or by telephone, an appeal of a decision not to certify a non-urgent
admission, procedure or service or extension of an Inpatient stay. For details of appeal procedures, please
refer to Section VIII-Claim Submission and Review Procedures under Plan Determination Notices and
Claimant Appeal.
Written Ap peals for adverse benefit determinations made by the POMCO Medical Services
Department should be sent to:
POMCO Medical Services Department Appeals
P.O. Box 6329
Syracuse, NY 13217
Phone: Toll-free # 1-800-501-9536
For all other Claim Appeals: See Section VIII-Claim Submission and Review Procedures under Plan
Determination Notices and Claimant Appeals.
Please Note
All claims are subject to a review to decide whether services are covered according to Plan limitations. A
second opinion consultation does not guarantee benefits. You must comply with requests for additional medical
documentation as deemed necessary by the Claims Administrator to evaluate a claim for benefits. Failure to
submit requested documentation or information or to provide a signed release for pertinent medical records
could result in denial of benefits. The Claims Administrator confidentially maintains all medical documents in
accordance with applicable New York State and federal laws. Treatment decisions are independent from
payment decisions. The patient's Physician is responsible for determining whether treatment should be
rendered despite whether the charges are totally or partially included in, or excluded from, coverage under the
Plan.
