Under your Plan’s Indemnity Medical option, prior authorization is required for all non-emergency hospital stays. Notice of emergency hospitalizations must also be approved as soon as possible following admission (within 72-hour maximum). Charges for non-certified hospital days are not covered under the Indemnity Medical option.
This page briefly explains the Indemnity Medical option’s Pre-admission Certification, Utilization Review and Case Management Procedures. For more information, see the Guide to Your Benefits and Summary of Coverage for your TBT plan or contact the TBT Plan Administration Office.
Prior Authorization Certification
Pre-admission Certification is required before you are covered for any non-emergency hospitalization. Call Blue Cross Life and Health 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 will result in a significant reduction of benefits. See the Summary of Coverage for your TBT plan for specific details. Charges for non-certified hospital days are not covered under your TBT Plan.
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 toll-free at (800) 274-7767. Once notified, the registered nurse coordinators and doctors at Blue Cross Life and Health conduct the certification and communicate their decisions to the doctor’s office, often during the 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 or chemical dependency treatment. Phone TAP at (800) 253-TEAM or (510) 562-3600 for Pre-admission Certification. Note: If you are a member of a Teamsters Local Union through Joint Council 38, the 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.
The best time for you to notify Blue Cross Life and Health (or TAP if applicable) is when your doctor schedules an in-hospital stay. You, your doctor and the hospital will receive a written follow-up notice from Blue Cross Life and Health by mail. If you have not received a notice, you should verify that Preadmission Certification has been conducted before going to the hospital. It’s a good idea to check with Blue Cross Life and Health (or TAP or TARP if applicable) in advance.
Remember, if Blue Cross Life and Health (the Plan’s Utilization Review Organization) determines that hospitalization is not necessary—or that hospital services are not medically necessary— you, your doctor and the hospital will be informed by Blue Cross Life and Health. Your doctor is contacted to confirm the need for hospitalization. Blue Cross Life and Health writes to tell you whether your hospital stay has been certified and, if so, for how long. The Plan does not cover charges for non-certified days in the hospital.
Blue Cross certifies the medical necessity of a hospital stay; however, certification does not guarantee eligibility or benefits. You must be eligible at the time of the hospital stay and the medical procedures must be covered by the Plan. There are also important deadlines related to claim filing procedures explained under the Claiming Benefits section of the Guide to Your Benefits (posted under your TBT Plan).
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. Blue Cross Life and Health is the Plan’s current Utilization Review Organization.
Utilization Review 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, your doctor must notify Blue Cross Life and Health in advance. If Blue Cross Life and Health determines that any in-hospital days are not medically necessary, these days are not covered.
The Utilization Review procedures are usually triggered by admission to a hospital. However, you must notify both the doctor and the hospital (either before or upon admission) that Utilization Review is required by the Plan. If the hospital treatment is for alcohol or chemical dependency, the Utilization Review procedures are conducted by TAP or TARP. For more information about TAP or TARP, see the Alcohol or Chemical Dependency Treatment Benefits section of the Guide to Your Benefits (posted under your TBT Plan).
Case Management
Under the Indemnity Medical Option, Blue Cross Life and Health (the Plan’s Utilization Review Organization) also reviews charges and appropriateness of outpatient services in light of the patient’s diagnosis and health care needs. In some cases, a patient’s needs may be met as well or better through an alternative to an acute care hospital confinement. Such treatment plans could include home, hospice or convalescent nursing home care.
Blue Cross Life and Health works with your physician to assess whether alternative care is suitable for the patient, to assure coordination of health care services and that these services are carried out in a way that ensures continuity and quality of care. The Plan covers alternative care only when it has been pre-approved by Blue Cross Life and Health.