Qualified Health Plan Medical Necessity and Precertification Requirements

For the inpatient and outpatient levels of care described below, the plan requires that you or your treating provider precertify the medical necessity of your care. Please note that precertification relates only to the medical necessity of care; it does not mean that your care will be covered under the plan. Precertification also does not mean that we have been paid all monies necessary for coverage to be in force on the date that services or supplies are rendered.

In some cases, your provider will initiate the precertification process for you. You should be sure to check with your provider to confirm whether precertification has been obtained. It is your responsibility to ensure that you or your provider obtains precertification.

Inpatient Hospital Benefits

Medical/Surgical

• Acute hospitalization
• Hospice care
• Long-term acute care hospital (LTACH)
• Rehabilitation services

Mental Health and Substance Use Disorders

• All non-emergency hospital admissions
  • Includes inpatient residential treatment programs
  • Excludes mental health and substance use disorder emergency services
• Detoxification services
  • Procedure codes requiring precertification: H0008, H0009, H0010, H0011, H0012, H0013, H0014

Outpatient Hospital Benefits, Physician Benefits, Other Covered Services

Precertification is required for certain outpatient hospital benefits, physician benefits and other covered services. The general categories or descriptions of outpatient hospital benefits, physician benefits and other covered services that require precertification at the time of the filing of this booklet are set forth below.

You can find more information about the following specific medical/surgical services that require precertification on the lists located within the website link(s). The list within the website link(s) will be updated no more than twice per calendar year. You should check the list within the website link(s) prior to obtaining any outpatient hospital services, physician services and other covered services.

Outpatient Services

Medical/Surgical

• Advanced imaging
• Genetic laboratory testing
• Home health services
• Hospice care
• Provider-administered drugs
• Radiation therapy management
• Select outpatient/office services

Mental Health and Substance Use Disorders

• Intensive Outpatient Programs (IOP)
  • Procedure codes requiring precertification: 905, 906
• Intensive Outpatient Programs (IOP)
  • Procedure codes requiring precertification: 912, 913