Precertification is required for the following services:

 Inpatient pre-admission and continued stay reviews (all ages, all diagnoses):

• • Surgical and non-surgical (excluding routine vaginal or cesarean deliveries);
  • Long-term acute care facility (LTAC), not custodial care;
  • Skilled nursing facility/rehabilitation facility; and
  • Inpatient mental health/substance abuse disorder treatment (includes residential treatment facility services)
• Inpatient and outpatient surgery including pain management injections and intra-articular hyaluronic acid injections (Pre-certification is not required for office surgeries and all colonoscopies/sigmoidoscopies (screening and diagnostic);
• Advanced imaging (CT studies, Coronary CT angiography, MRI/MRA, nuclear cardiology, nuclear medicine (including SPECT scans) and PET scans (excluding services rendered in an ER setting);
• Outpatient rehabilitation services (physical, occupational and speech therapy) in excess of twenty (20) visits per plan year per therapy type;
• Chemotherapy drugs/infusions and radiation treatments for oncology diagnoses;
• Home health care services and supplies;
• Transplant (other than cornea), including, but not limited to, kidney, liver, heart, lung, pancreas, and bone marrow replacement to stem cell transfer after high dose chemotherapy;
• Orthotics/Prosthetics over three thousand dollars ($3,000);
• Durable Medical Equipment over three thousand dollars ($3,000) (purchase/rental price);
• Genetic testing/genomic testing (excluding amniocentesis) in excess of one thousand dollars ($1,000);
• Clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition (This Plan does not cover clinical trials related to other diseases or conditions.);
• Non-emergent air ambulance;
• Intensive outpatient program in excess of twenty (20) visits per benefit year, for mental health and substance abuse disorder treatment;
• Specialty infusion/injectable medications over three thousand dollars ($3,000) per infusion/injection which are covered under the medical benefit and not obtained through the prescription benefit program (i.e., provided in an outpatient facility, physician’s office, or home infusion); and
• Dental services required for medical procedures.

 

PLEASE REFER TO THE SUMMARY PLAN DOCUMENT FOR MORE INFORMATION!

 

What is the procedure for obtaining pre-certification?

 

For all non-emergency procedures that require pre-certification, the Covered Person or his/her Physician must contact AmeriBen prior to the admission or in advance of the procedure at 855.778.9053 at least forty eight (48) hours before services are scheduled to be rendered.  AmeriBen will review the request for services and contact the Physician for any records or additional information necessary to thoroughly evaluate the need for services.   Benefit eligibility for the pre-certified procedures must be verified with AmeriBen prior to completing services.

 

For emergency procedures or hospital admissions, the Covered Person, his/her Physician, the hospital admissions clerk, or anyone associated with the Covered Person's treatment, must notify AmeriBen by telephone within forty-eight (48) hours of the procedure or the admission