Outpatient Hospitalization

Outpatient Hospitalization

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Please note: the information on this page is provided as a basic reference and should not be considered all-inclusive. Please refer to your Customer Guide, Summary of Plan Document, or benefit plan for complete details.

See your Customer ID card for the Customer Service phone number and a summary of when to call. Services are available toll-free to answer questions to determine if and how services are covered under your benefit plan.

Outpatient Surgery

To obtain the highest level of benefits for an outpatient hospitalization, it's important to follow the requirements stipulated by your policy. Before your next outpatient hospitalization, make sure to verify the following information.

Check into the following:

• What hospitals are part of your plan network? Visit Find a Doctor to assist you.
• Will needed follow-up care, such as nursing home or home health care, be covered by the plan?
• If I have a serious medical problem, will my plan provide someone to oversee care and make sure my needs are met?
• Understand how your benefit plan handles getting a second doctor's opinion on whether surgery or another treatment is needed. Are second opinions encouraged or required? Who pays?

Prior Authorization

Prior Authorization is a review process which takes place during outpatient service situations, they're enacted according to the requirements of your policy or can be enacted at your request.

A team of medical professionals review prior authorization. They determine if your proposed service is covered in your benefit plan, and if it's medically necessary (as per your plan's definition) for your care.

Before deciding a course of action on a particular outpatient medical service, please check your benefit plan and determine if any prior authorization is required prior to proceeding.

Below are some examples of medical services for which prior authorization is strongly encouraged:

• Durable Medical Equipment (DME) or orthotics with rental price above $750 per month or purchase price above $1,000 require a prior authorization. Continuous glucose monitors require a prior authorization if more than $10,000 in cost.
• Any surgery that ends in "plasty" (e.g., mammoplasty, gastroplasty).
• Sleep studies, polysomnograms for assessment of obstructive sleep apnea.
• Excision or ligation of varicose veins.
• Transplants/implants of body organs, tissue-to-tissue exclusion.
• New medical or biomedical technology (e.g., Positron Emission Tomography (PET) scans).
• Sticky glue into uterine arteries.
• All injections for pain management (e.g., epidurals or facet injections).

To request a prior authorization, please call the phone number listed on your ID card.

When to Call

Outpatient surgery or services (only if required by your plan) At least three business days in advance