6.5 PRECERTIFICATION REVIEW Precertification Review is a procedure administered by the Utilization Management Organization to assure that the admission and length of stay in a Hospital or specialized facility, surgery or other health care services are Medically Necessary. The Utilization Management Organization determines if recommended confinements, surgery or other health care services meet or exceed accepted standards of care. If additional information is needed, the Utilization Management Organization will advise the caller. The Utilization Management Organization will review the information provided, and will let you, your Physician and the Hospital (or other provider), and the Administrative Office know whether or not the proposed services have been certified as Medically Necessary. The Utilization Management Organization will respond to your Physician or other provider by telephone shortly after the Utilization Management Organization receives the request and any required medical records and/or information, and the determination will then be confirmed in writing. When to Call: – Prior to any scheduled procedure or service listed below – Within 72 hours of an emergency inpatient hospitalization 6.5.1 WHAT SERVICES AND PROCEDURES REQUIRE PRECERTIFICATION OR PRE-SURGICAL REVIEW Precertification Review is required for all inpatient hospital admissions. Precertification Review IS REQUIRED for Emergency inpatient hospitalization. If an Emergency requires admittance into the Hospital, the Utilization Management Organization must be contacted within 72 hours. Your Physician, a family member or friend can make that phone call. This will enable the Utilization Management Organization to advise you on the Medical Necessity of health services. vPre-surgical Review is required for the following outpatient surgical procedures: Abdominoplasty/Panniculectomy and Lipectomy Abdomen; these procedures are not covered if due to Gastric Bypass/Bariatric Surgery. Gastric Bypass/Bariatric Surgery is a specific exclusion under the Plan’s provisions. Back Surgery: Discetomy, Laminectomy and Spinal Fusion; 2nd surgical opinions are appropriate on back surgeries when indicated Breast Surgery: Breast Reconstruction, Mammoplasty (Unilat Reduction), Mammoplasty (Bilat Reduction) Hysterectomy: Abdominal Hysterectomy, Vaginal Hysterectomy, Unspecified Hysterectomy Knee Surgery: 3 in 1 repair, 5 in 1 repair, Arthroscope, Arthrotomy, Menisectomy, Other rep of coll, other rep of knee, other repair, Patellar Stabil., Re-alignment, Revision of knee, Tendon/Patella, Total knee replacement All Nasal Surgeries Orthognathic surgery – (Jaw and/or TMJ); TMJ is an exclusion under Plan. Uvulopharygnoplatatoplasty (UPPP), Palatopharyngoplasty Bunionectomy and/or hammertoe (multiple) Varicose Vein Surgery 6.5.2 EXCEPTIONS TO PRECERTIFICATION REVIEW Precertification Review is NOT REQUIRED when this Plan is the secondary payor. Precertification Review is NOT REQUIRED for Participants with Medicare as the primary payor, as Medicare has its own review program. Precertification Review is NOT REQUIRED for a Medically Necessary emergency room visit. Precertification is NOT REQUIRED for the following services and procedures. However, since these services are frequently in connection with potentially serious medical conditions, you may wish to contact the Utilization Management Organization to review any concerns you have. You may request Precertification of any health care service that is not required in order to be assured that the service is Medically Necessary. Outpatient surgical procedures; other than those specifically listed Diagnostics: includes heart catherizations, CT scans, MRIs, ultrasounds, IVPs (radiographic exam of kidneys, ureter and bladder), etc. Nursing and Rehabilitation Facility services Hospice Care Orthotics and Prosthetics over $100 Second Surgical Opinions 6.5.3 SECOND MEDICAL OPINION FOR PRE-SURGICAL REVIEW: If the Plan requires a second medical opinion, the Utilization Management Organization will arrange for an examination by a Physician who: is certified by the American Board of Medical Specialists in the field related to the proposed service; is independent of the Physician who proposed the service; and will not perform the service. The second medical opinion Physician may review past medical records along with clinical findings from his/her own examination of the Participant, and will report to the Utilization Management Organization. If the second opinion recommendation differs from the treating Physician’s recommendation, the Plan may obtain a third medical opinion from another Physician who will be selected by the Utilization Management Organization. The results of the third opinion will be reviewed by the Utilization Management Organization, and the recommendation of the majority of Physicians (the attending Physician, second and third medical opinion Physicians) will prevail. Participant-Requested Second Medical Opinion You may request a second medical opinion in conjunction with Pre-surgical Review requirements. If, as a result of the second and/or third medical opinion, it is determined that the procedure recommended by the treating Physician is not Medically Necessary, the Plan will not pay benefits for the proposed surgical procedure. If a second medical opinion is not required for Pre-surgical Review, but you or your Dependent would like to request one, it will be a Covered Expense. 6.5.4 REQUEST FOR REVIEW OF DENIAL OF BENEFITS BASED ON PRECERTIFICATION REVIEW Regular Request for Review If the Utilization Management Organization determines that the proposed service is not Medically Necessary, you and/or your Physician may submit a written request for review accompanied by any additional information to support the need for the proposed service. The request for review should be sent to the Utilization Management Organization. You can expect that the Utilization Management Organization will respond in writing within 30 days after receiving the request and any required medical records and/or information. Expedited Request for Review If the Utilization Management Organization determines that the proposed service is not Medically Necessary, the treating Physician may telephone the Utilization Management Organization to request an expedited review with the medical director or a Physician designated by the Utilization Management Organization to provide the necessary review. the Utilization Management Organization will usually respond to your Physician by telephone within 24 working hours, and later confirm the determination in writing to you, your Physician, and the Administrative Office. Independent Review of a Denial of Precertification If the Utilization Management Organization confirms the initial determination that the proposed service is not Medically Necessary, you and/or your Physician may submit a written request for an independent medical review of the denial of precertification. Call the Trust Customer Service Office for information regarding this independent review. The independent medical reviewer will consider all information presented by your Physician and the Utilization Management Organization. You can expect a written response regarding this review from the Trust within 60 days after your request for such a review is received. If the independent medical reviewer determines the service is not Medically Necessary, you may request review by the Administrative Committee pursuant to the Review Procedure explained at Section 6.5.4. 6.5.5 CONCURRENT (CONTINUED STAY) REVIEW When you are receiving medical services in a Hospital or specialized facility, the Utilization Management Organization may contact you to assure that continuation of medical services is Medically Necessary. Concurrent Review may include such services as: coordinating Home Health Care or the provision of Durable Medical Equipment; determining the Medical Necessity of continued medical services; and/or advising you of the various options covered under this Plan for your medical care. The Plan pays no benefits for charges related to days of confinement in a Hospital or specialized facility that have not been determined to be Medically Necessary. 6.5.6 REQUEST FOR REVIEW OF A DENIAL OF BENEFITS BASED ON CONCURRENT REVIEW If the Utilization Management Organization determines continued services are not Medically Necessary, you and/or your Physician will be notified and you will have the opportunity to request review of the determination. The obligation to request review rests entirely with you. The review procedures for concurrent review are the same as those for precertification review; see Section 6.5.4.