Bakery Drivers Local 734 - Health and Welfare Fund | Medical Care Review Program
15793
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Medical Care Review Program

Medical Care Review Program

You should already have received a brochure explaining how the Medical Care Review Program works. The brochure includes “Pre-Admission Review Request” forms. If you don’t have a brochure, contact the Fund Office.

Precertification by Med-Care DOES NOT guarantee payment of benefits. The Plan’s normal coverage rules and limitations still apply.

Hospitalizations and Surgery

Non-Emergencies
When your doctor recommends surgey or a hospital admission for you or a covered family member, the following rules apply if you want to get the maximum benefits possible:

    • Med-Care must be notified as soon as the hospitalization or surgery is recommended (this applies to both inpatient and outpatient surgery).

 

    • Med-Care’s review and certification must be performed before the hospital admission or surgery.

 

  • Med-Care will tell you if a second surgical opinion is required.

Of course, the final choice about your medical care is always up to you and your doctor.

Emergencies
If you or a covered family member are admitted to a hospital due to an emergency, Med-Care must be contacted no later than the next business day following the admission if you want to get the maximum benefits possible. You, your doctor, or a family member may make the call, but it is ultimately your responsibility to see that the call is made.

Other Types of Medical Care
Before receiving any care for the treatments or conditions listed below, you or your doctor must call Med-Care for precertification that the treatment is medically necessary and meets the Plan’s coverage requirements.

Review Organization (Med-Care)
Call 1 (800) 367-1934

Call for review and precertification of ALL:

  • Hospital Admissions
  • Surgeries (inpatient and outpatient)
  • Chiropractic care
  • Treatment for chemical dependency and mental/nervous disorders
  • Infertility-related services
  • Obesity surgery
  • Speech therapy
  • Podiatric (foot) surgery
  • TMJ treatment (medical or surgical)
  • Home health care
  • Durable medical equipment
  • Hospice care
  • Physical therapy

If the Treatment is Not Precertified

If you fail to follow the rules of the Medical Care Review Program, your benefits will be reduced or denied as follows:

20% Reductions
The benefits that would otherwise be payable for the following expenses will be reduced by 20% if Med-Care does not certify that the treatment is medically necessary:

  • Hospital Admissions
  • Surgery (or if a recommended second opinion is not obtained)
  • Home health care
  • Treatment for chemical dependency or mental/nervous disorders (except office visits)
  • Speech therapy
  • Physical therapy

Benefit Denials
The Plan will NOT PAY ANY benefits for the following expenses if Med-Care does not certify that the treatment is medically necessary and meets the Plan’s coverage requirements:

  • Chiropractic Care
  • Surgical facility fees for podiatric surgery
  • Infertility-related services
  • Obesity treatment
  • TMJ treatment
  • Durable medical equipment
  • Hospice care
  • Room and board charges for non-authorized (extra) days of hospitalization