Hospital requirements - Pre-admission Certification and Utilization Review / Back

Pre-admission Certification is required before you will be covered for any non-emergency hospitalization. Call Blue Cross Life and Health toll free at (800) 274-7767 or make sure your doctor calls Blue Cross Life and Health before scheduling the hospital stay. Failure to obtain Pre-admission Certification may result in a reduction of benefits. Charges for non-certified hospital days are not covered under the Plan.

IMPORTANT
Limitation for TBT Plan IV and Comprehensive Retiree Plan participants only. Failure to obtain Pre-admission Certification will result in a 20% reduction in benefits otherwise payable.

In an emergency, Blue Cross Life and Health must be notified as soon as possible following admission (and no later than 72 hours after admission). The doctor's office must call Blue Cross Life and Health at (800) 274-7767. Once notified, the registered nurse coordinators and doctors at Blue Cross Life and Health will conduct the certification and communicate their decisions to the doctor's office, often during that same phone call.

For hospitalization for alcohol or chemical dependency treatment, different Pre-admission Certification procedures are required before an in-hospital stay. The Teamsters Assistance Program (TAP) must pre-certify and oversee hospitalization due to alcohol and chemical dependency treatment. Phone TAP at (800) 253-TEAM or (510) 562-3600 for Pre-admission Certification. However, if you are a member of Teamsters Locals 94, 137, 150, 386, 431, 439 or 533, the Joint Council 38 Teamsters Alcohol Rehabilitation Program (TARP), rather than TAP, oversees hospitalization due to alcohol and chemical dependency treatment. Phone TARP at (800) 522-8277 or (209) 572-6966

Utilization Review

Utilization Review is also required during all hospitalizations to monitor required services and related charges—even if the admission was due to an emergency. This ensures that the hospital stay is medically necessary and appropriate in length. If your doctor concludes that the inpatient stay needs to be longer than certified, Blue Cross Life and Health must also be notified in advance by your doctor. If Blue Cross Life and Health determines that any in-hospital days are not medically necessary, these days will not be covered.

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