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 |
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Call for review and precertification of ALL:
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If the Treatment is Not Precertified |
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If you fail to follow the rules of the Medical Care Review Program, your benefits will be reduced or denied as follows: 20% Reductions
Benefit Denials
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