5.6 INPATIENT HOSPITAL SERVICES
All Hospital confinements are subject to Precertification Review by the Utilization Management Program. Precertification Review only certifies the Medical Necessity of proposed treatment; it does not guarantee that a Participant is eligible for Plan benefits when services are received. Call the Trust Customer Service Office for questions regarding eligibility and benefits.
If a Participant is admitted to a Hospital due to Illness or Injury, Benefits will be extended for:
- Daily room and board charges up to the Hospital’s charge for a semi-private room for each day of confinement. The Plan will cover a private room or intensive care unit if Medically Necessary.
- Hospital charges for other ancillary services and supplies provided during confinement. Hospital ancillary services or supplies may include:
- General nursing services (not private duty nursing)
- Use of operating and cystoscopic rooms
- Surgical and anesthetic supplies, splints, casts and dressings
- Oxygen, drugs and medical equipment utilized during confinement
- Laboratory and x-ray examinations, physiotherapy and/or hydrotherapy
- Take-home medications dispensed by the Hospital pharmacy at the time of discharge
Pursuant to the Newborns’ and Mothers’ Health Protection Act, the Plan covers a hospital length of stay in connection with childbirth for the mother or newborn child for 48 hours following a vaginal delivery, and 96 hours following a cesarean section delivery. The mother’s or newborn’s attending provider, after consulting with the mother, may, however, discharge the mother or her newborn child earlier than 48 hours (or 96 hours if applicable). Preadmission review is only required for lengths of stay expected to exceed the 48-hour/96-hour limits.