Precertification

If a participant is enrolled in the MedPlus plan, MedBasic plan, Catastrophic plan, or Out-of-Area plan and needs hospitalization, skilled nursing care, home health care, hospice care or convalescent facility care, the participant is responsible for following the requirements for Preadmission Certification and Continued Stay Review (also known as "precertification"). Preadmission Certification and Continued Stay Review are procedures used to certify the medical necessity and length of any hospital confinement for inpatient care.

If a participant or a dependent is scheduled for a hospital admission, the participant should call the number on his or her Medical ID card before admission and request precertification. Obtaining precertification is the participant's responsibility. Even if the doctor agrees to initiate admission, the participant must follow up to ensure that it has been accomplished.

A PPO network customer service representative will work with a participant's doctor to ensure that the hospitalization is appropriate, medically necessary, and timely, and then let the participant know the number of days for which admission has been certified.