Cheryl A. Thompson ,3h DO N
From: Eva Hyde [ehyde@co.kerr.tx.us]
Sent: Monday, February 26, 2007 12:02 PM
To: Cheryl A. Thompson
Subject: FW: Utilization Management Rider - Kerr County
487AGUSIPPO UM
Rider.pdf (17 K...
Cheryl,
Can you use this instead of me printing it out and then having you scan it to go with
the 2007 insurance file.
Thank You,
-----Original Message-----
From: Connie.Potter@mutualofomaha.com
[mailto:Connie.Potter@mutualofomaha.com]
Sent: Monday, February 26, 2007 9:28 AM
To: ehyde@co.kerr.tx.us
Cc: dawallace@satx.rr.com; michelleb@satx.rr.com; glooney@alamoinsgrp.com
Subject: Utilization Management Rider - Kerr County
Attached is the electronic copy of the Medical Product policy material for
Kerr County. The attached document(s) represent an electronic version of
the Certificate Booklet Rider(s). Changes to the Certificate Booklet:
Medical Product: A Rider was issued due to the Utilization Management
Provisions removed the Outpatient High End Radiology information
effective 02/01/07.
Please retain this copy for future use.
Thanks you.
Connie Potter
San Antonio Health Office
Mutual of Omaha
ph: 888-929-4964 or 210-903-2799
fax: 210-494-5765
(See attached file: 987AGUSIPPO UM Rider.pdf)
This e-mail and any files transmitted with it are confidential and are
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(Please keep with your booklet)
Kerr County
Important Change(s) to Your Plan
Effective February 1, 2007
UTILIZATION MANAGEMENT PROVISIONS
UTILIZATION REVIEW
This Plan Change is made a part of an Administrative Services Agreement which is comprised of Group
Identification Number 0000487A and Plan Identification Number MEDPPO.
This Plan Change is effective the later of February 1, 2007, or the day You become covered under the
Plan.
The Precertification requirement for Outpatient High End Radiology is being removed from the
Utilization Management Provisions.
This UTILIZATION MANAGEMENT PROVISIONS replaces any previous UTILIZATION
MANAGEMENT PROVISIONS in the Booklet to which it is attached.
In the event of a conflict between this Plan Change and any other provision of the Plan, including the
Booklet, this Plan Change shall control. This Plan Change shall be subject to all provisions of the Plan,
including the Booklet, not in conflict with this Plan Change.
UTILIZATION REVIEW
Utilization Review Procedures are only intended to determine if health care services or supplies
are Medically Necessary under the terms of the Plan.
Before the services or supplies are received, all Hospital Confinements, Outpatient Surgical
Procedures and Specialized Services and Supplies identified in these provisions must be pre-certified by
United as Medically Necessary. You, not Your Physician, are responsible for making sure a
pre-certification determination has been made. However, You, Your representative or Your
Physician may initiate the pre-certification.
Pre-certification of a proposed service or supply as Medically Necessary through the Utilization
Review process does not necessarily mean that benefits are payable. Confirmation of a person's
eligibility for Plan coverage for a particular service or supply, and fulfillment of all other Plan
requirements, are also necessary for benefits to be payable.
Definitions
Care Review Unit means United's Care Review Unit staff or a qualified party or entity named by them.
For the toll-free phone number, refer to Your identification card or contact Your Plan Administrator.
Outpatient Mental and Nervous Disorders or Alcohol and Drug Abuse and/or Chemical
Dependency Therapy means any individual, group, family or intensive outpatient therapy for the
treatment of a Mental and Nervous Disorder or Alcohol and Drug Abuse and/or Chemical Dependency,
regardless of how it is classified.
Outpatient Surgical Procedures means the outpatient surgical procedures listed below which are
performed:
(a) in an ambulatory surgical facility;
(b) in a Physician's office or clinic; or
(c) on an outpatient basis in a Hospital.
Outpatient surgical procedures include:
(a) carpal tunnel release -surgery to relieve a pinched nerve in the hand;
(b) cochlear implants -insertion of small computer device to transmit to the auditory nerve;
(c) endometrial ablations -complete removal of the lining of the uterus;
(d) hysterectomy -surgical removal of the uterus;
(e) pelvic laparoscopy -examination of the female organs by a scope;
(f) tonsillectomy with/without adenoidectomy -surgical removal of the tonsil and adenoids;
(g) septoplasty -surgical procedure to straighten the nasal septum; and
(h) UPP (uvulopalatopharyngoplasty) or laparoscope aided UPP -removal of a portion of the uvula
and soft palate.
Specialty Drugs and Medicines means the injectable specialty drugs or medicines for the ongoing
treatment of a chronic condition which are given:
(a) in a Physician's office or clinic; or
(b) in a home health care setting.
Specialty Drugs and Medicines includes, but is not limited to, those used for the following:
(a) asthma;
(b) inflammatory bowel disease;
(c) growth hormone deficiency;
(d) neurologic disease;
(e) osteoporosis;
(f) psoriasis;
(g) rheumatoid arthritis;
(h) immune deficiency;
(i) injectab]e drugs or medications with uses for indications excluded under the Plan.
Specialized Services and Supplies means the services or supplies listed below:
(a) home health care;
(b) outpatient hospice care;
(c) durable medical equipment: the purchase or rental of any single piece of durable medical
equipment with a purchase price of $1,000 or more; and
(d) prosthetics.
Pre-certification Requirements
You must pre-certify with United the following:
1. Hospital Confinement, Skilled Nursing Facility confinement and inpatient Hospice Care Facility due
to a Sickness or Injury;
2. Hospital Confinement and partial hospitalization for Mental and Nervous Disorders or Alcohol and
Drug Abuse and/or Chemical Dependency;
3. Outpatient Mental and Nervous Disorders or Alcohol and Drug Abuse and/or Chemical Dependency
Therapy;
4. Specialty Drugs and Medicines;
5. Outpatient Surgical Procedures; and;
6. Specialized Services and Supplies.
You, Your representative or Your Physician must request pre-certification from the Care Review Unit.
The Care Review Unit will advise You and Your Physician of the review decision.
United recommends pre-certification be initiated at least seven (7) days before the Hospital
Confinement, Outpatient Surgical Procedure, Outpatient Mental and Nervous Disorders or Alcohol and
Drug Abuse and/or Chemical Dependency Therapy or Specialized Services and Supplies begin or are
received. If not pre-certified at least one (1) business day prior, a penalty will apply.
Within two (2) business days, or as soon as reasonably possible for a Medical Emergency, You, Your
representative or Your Physician must notify the Care Review Unit of the Hospital Confinement, the
Outpatient Surgical Procedures and/or the Specialized Services or Supplies. If not pre-certified within
this time frame, a penalty will apply. The Care Review Unit will advise You and Your Physician of the
review decision.
If a visit to a Hospital Emergency room exceeds 24 hours, any additional observation in the emergency
room must be pre-certified. This is applicable even if the visit does not result in a Hospital Confinement.
Effect on BeneTits
The following penalties will apply if services are not properly pre-certified by United.
1. For Hospital Confinement due to a Sickness or Injury, Skilled Nursing Facility, inpatient Hospice
Care Facility, Hospital Confinement and Partial Hospitalization for Mental and Nervous Disorders
or Alcohol and Drug Abuse and/or Chemical Dependency:
Prior to admission, if a Covered Person does not first initiate the required pre-certification and it is
determined that the Hospital Confinement and related Covered Services were:
(a) Medically Necessary, benefits payable for the room and board will be reduced by $500; or
(b) not Medically Necessary, no benefits are payable.
During the confinement, if a Covered Person has received pre-certification for a specified number
of days and wants to stay for additional days, the additional days must be approved by United as
described in the Pre-certification Requirement section. If the additional days are not pre-certified by
United and subsequent review determines the days were;
(a) Medically Necessary, benefits payable for the room and board will be reduced by $500; or
(b) not Medically Necessary, no benefits will be payable.
Note: For Services that could have been provided on an outpatient basis, but are performed in an
inpatient/Hospital Confinement setting when Hospital Confinement was determined to not be
Medically Necessary, the room and board will not be payable. Expenses for other Covered Services
provided during the Hospital Confinement (including but not limited to x-ray and laboratory
services) will be considered in accordance with applicable Plan provisions.
2. For Outpatient Surgical Procedures, Outpatient Mental and Nervous Disorder/Alcohol and Drug
Abuse and/or Chemical Dependency, Specialized Services or Supplies, or Non-Retail Specialty
Drugs and Medicines:
Prior to treatment, if a Covered Person does not first obtain the required pre-certification and it is
determined that the Covered Services were:
(a) Medically Necessary, benefits payable will be reduced by $500; or
(b) not Medically Necessary, no benefits are payable.
During the treatment, if a Covered Person has received pre-certification for a specified number of
days/visits/treatments and wants additional days/visits/treatments, the additional
days/visits/treatments must be approved by United as described in the Pre-certification Requirement
section. If the additional days/visits/treatments are not pre-certified by United and subsequent review
determines the days/visits/treatments were:
(a) Medically Necessary, benefits payable will be reduced by $500 per days/visits/treatments; or
(b) not Medically Necessary, no benefits will be payable.
When benefits are reduced in accordance with this Effect on Benefits section, the reduction will not be
used to satisfy any deductible or out-of-pocket limit shown in the Schedule.
Exceptions
1. Pre-certification is not required when the Covered Person has Medicare coverage which:
(a) has primary responsibility for the Covered Person's claim; and
(b) must pay its full benefits before Plan benefits are paid in accordance with the Medicare
Coordination of Benefits provision of the Plan.
2. Pre-certification is nut required for the initial 48-hour inpatient Hospital Confinement for a vaginal
delivery or the 96-hour inpatient Hospital Confinement for a Cesarean section delivery.
3. Pre-certification is not required for services or supplies performed or provided, outside the United
States, Mexico and Canada or any state, district, province, territory or possession thereof.
Request for an Appeal of United's Utilization Review Decision
You, Your representative or Your provider of health care have the right to request an appeal regarding
United's Utilization Review decisions. The request should be submitted in writing and should include
any additional information that may have been omitted from United's review or that should be
considered by United. Requests should be sent to:
Mutual of Omaha
Medical Management
Appeals and Grievance
PO Box 31640
Omaha, NE 68131-0640
You may also call the toll-free phone number listed on Your identification card for additional
information regarding United's appeal process.
Administrative Services Agreement
which is comprised of
Group Identification Number G000487A
and
Plan Identification Numbers MEDPPO
Murua~~Omaxa
Publication Date: February 24, 2007