Bakery Drivers Local 734 | Medical Care Review Program
15793
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Medical Care Review Program

Medical Care Review Program

PRECERTIFICATION BY MED-CARE MANAGEMENT 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 surgery or a hospital admission for you or a covered family member, the following rules apply if you want to get the max-imum 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.

The decision by Med-Care to pre-certify your hospitalization or surgery determines the Plan’s payment obligations; 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.

Call 1 (800) 367-1934 FOR REVIEW

Call for review and precertification of ALL:

  • ABA therapy
  • Abortion
  • Acupuncture
  • Aqua therapy
  • Chiropractic care
  • Durable medical equipment & supplies
  • Genetic Testing
  • Home health care
  • Hospice care
  • Hospital admissions
  • Infertility-related services
  • Massage therapy
  • Nutrition counseling
  • Obesity surgery
  • Occupational therapy
  • Physical therapy
  • Podiatric (foot) surgery
  • Skilled nursing facility con-finements
  • Sleep studies
  • Speech therapy
  • Surgeries
  • TMJ treatment (surgical)

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:

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

20% Reductions
In addition, the benefits that would otherwise be payable for the following expenses will be reduced by 20% if Med-Care does determine them to be medically necessary, but they were not PRE-certified (certified to be medically necessary BEFORE they were incurred):

  • Hospital admissions
  • Surgery (20% reduction also applies if a recommended second opinion is not ob-tained)
  • Home health care
  • Occupational therapy
  • Physical therapy
  • Speech therapy