Preauthorization rules for McLane Employees

Preauthorization Requirements

Preauthorization establishes in advance the Medical Necessity of certain care and services covered under this Plan. It ensures that the preauthorized care and services described below will not be denied on the basis of Medical Necessity. However, preauthorization does not guarantee payment of benefits. Coverage is always subject to other requirements of the Plan, such as Preexisting Conditions, limitations and exclusions, payment of contributions, and eligibility at the time care and services are provided.

The Claims Administrator's Health Services Division has the responsibility of issuing preauthorization and determining when a second opinion is necessary. All services listed below, including surgery, require preauthorization. Some additional procedures and surgeries require a second opinion and/or preauthorization.

The following is a general list of the types of services (see Schedule of Benefits and Description of Benefits for information specific to Core or Premium) that require preauthorization:

Dermatology including but not limited to:
- Mohs surgery
- Dermabrasions
- Benign lesion removal
- Ultraviolet light treatments
Plastic surgery procedures
Selected injectable drugs (see formulary for current list which is updated regularly)
Cardiac rehabilitation programs
Pulmonary rehabilitation programs
Home care services
Hospice services
Sleep studies
Transplant evaluations/procedures
All hospitalizations, including surgical
All admissions to:
- Ambulatory care centers
- Mental Health/Substance abuse centers
- Inpatient rehabilitation centers
- Skilled nursing facilities/units
- Long-term acute care facilities

The following surgical procedures may require second opinions:

Breast
Joint
- Hip
- Knee
- Jaw, etc.
Nasal
Spine
Transplants
Varicose veins

Preauthorization is simple. You or your Dependent, your Physician, Provider of services, or a family member (if you have granted them access to your health information on a "Release of Information Form") should request preauthorization prior to any non-emergency treatment described above. In the case of an elective inpatient admission, the request for preauthorization should be made at least 2 working days before you are admitted unless it would delay Emergency Care. In the case of an admission for Emergency Services, you must contact the Review Organization within 2 schedule working days after the admission.

You are not required to request preauthorization prior to an admission due to childbirth, but the Claims Administrator requests that you notify Health Services Division at the time of your admission for delivery. Preauthorization should be requested, prior to the end of the minimum length of stay (listed below), for continued Hospital Confinement.

When an inpatient admission is preauthorized, a length-of-stay is assigned. This Plan is required to provide a minimum length of stay in a Hospital facility for the following:

Maternity Care:
48 hours following an uncomplicated vaginal delivery
96 hours following an uncomplicated delivery by caesarean section

Treatment of Breast Cancer:
48 hours following a mastectomy
24 hours following a lymph node dissection

If you require a longer stay than was first preauthorized, your Provider may seek an extension for the additional days. Benefits will not be available for room and board Charges for medically unnecessary days.

Preauthorization for Home Health Services (Out-of-Network), Skilled Nursing, and Hospice (Out-of-Network) may be obtained by having the agency or facility providing the services contact the Claims Administrator to request preauthorization. The request should be made by the physician or member by calling the preauthorization phone number (listed below) at least 3 to 5 days in advance of:

Initiating Extended Care Expense or Home Infusion Therapy;
When an extension of the initially preauthorized service is required; and
When the treatment plan is altered.

The Claims Administrator will review the information submitted prior to the start of Home Health Services (Out-of-Network), Skilled Nursing, and Hospice (Out-of-Network) services. The Claims Administrator will send a letter to you and the agency or facility confirming preauthorization or denying benefits. If the care is to take place in less than 1 week, the agency or facility should call the applicable telephone number previously listed below. If the Claims Administrator has given notification that benefits for the treatment plan requested will be denied based on information submitted, claims will be denied.

Preauthorization Phone Number

The Claims Administrator's Health Services Division has the responsibility of issuing preauthorization and determining when a second opinion is necessary. To satisfy all preauthorization requirements listed above, call the Preauthorization Line before any of the surgeries or procedures are done, Monday through Friday, 8:00 a.m. - 5:00 p.m., Central Time. Calls made after working hours or on weekends will be recorded and returned the next working day. A benefits management Nurse will follow up with your Provider's office.

Toll-free: 1-888-316-7947
Local: (254) 298-3088

Penalties for Failure to Preauthorize

Other than in connection with childbirth, the penalty for not getting the required preauthorization before treatment is:

$200.00 for each out-of-network elective admission
50% for each procedure requiring second opinions

You can not include this penalty as a covered expense for the purposes of meeting the Annual Out-of-Pocket maximum nor do any of the covered charges apply towards satisfying the Out-of-Pocket maximum. If preauthorization is not obtained for the services listed above:

The Claims Administrator will review the Medical Necessity of your treatment prior to the final benefit determination. If the Claims Administrator determines the treatment or service is not Medically Necessary, benefits will be denied; or
You may be responsible for a $200.00 or 50% benefit reduction penalty. The penalty charge will be deducted from any benefit payment which may be due.
If a Hospital Admission or extension for any treatment or service described above is not preauthorized and it is determined that the admission or extension was not Medically Necessary, benefits will be reduced or denied.