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HOSPITAL CERTIFICATION PROGRAM
A different certification program applies to inpatient admissions and other types of treatment for substance abuse and mental or nervous disorders—see the “Mental Health Review Program” on page 56 for the rules governing those types of treatment.
The Hospital Certification Program is administered by Medical Cost Management (MCM). MCM will work with you and your doctor to help you avoid unnecessary hospital days. Your family will still get benefit coverage under the terms of the Plan for all of the hospital care that is needed. Of course, only you and your doctor make the decisions about your medical care and treatment.
Hospital Certification Noncompliance Deductible - A $250 deductible will apply to the covered medical expenses incurred during each hospitalization where the required procedures of the Hospital Certification Program are not followed. Any such deductibles are in addition to the calendar year deductible. The deductible will not apply to any hospital stay for which the procedures are followed.
How to Have Hospital Admissions Certified - To start the certification process, you, your doctor or the hospital must call the Fund Office’s toll-free number and ask for the MCM hospital certification personnel. Be sure the call is made within the time limits explained below.
FOR CERTIFICATION OF HOSPITAL ADMISSIONS
Call the Fund Office at 1-(800)-323-7268
8:30 a.m.-4:30 p.m., CST
Ask for Medical Cost Management (MCM)
- Non-Emergency Hospital Admissions - If your doctor proposes a hospital admission for a family member, you or the doctor must call the Fund Office before the admission to give MCM details about the admission.
- Emergency Hospital Admissions - If a family member is admitted to a hospital due to an emergency, you or your doctor must call the Fund Office within two working days after the admission to let MCM know the reason for the admission and what services the person is receiving. (Treatment in a hospital's emergency room is not an emergency admission and does not require a call to the Fund Office unless the person is admitted to the hospital as an inpatient.)
- Maternity Admissions -If a female employee, retiree or spouse is going to enter the hospital to have her baby, she or her doctor should call as soon as the pregnancy is confirmed (or during the first trimester) to let MCM know that she will be entering the hospital for delivery. The approximate admission date should be provided. Then, after admission, she should call as soon as possible, and at least within 12 hours after delivery, to tell MCM about the delivery. MCM must also be called within two working days after an admission for any pregnancy-related conditions such as false labor, miscarriage, etc. The $250 hospital certification noncompliance deductible will not apply to inpatient hospital care following a normal delivery lasting 48 hours or less, or inpatient hospital care following a Caesarean section lasting 96 hours or less. It will apply to other pregnancy-related confinements if MCM is not contacted as described above.
Although it is best to have your doctor make the call—you, a family member, or the hospital can call the Fund Office to tell MCM about a hospitalization. IMPORTANT - No matter who makes the call, it is your responsibility to see that the call is made.
After the call has been made to MCM about a proposed hospital admission, you will be sent a letter explaining MCM's recommendations regarding certification of the hospital stay under the terms of the Plan. This letter is your proof that the procedures of the Hospital Certification Program were followed and that the noncompliance deductible won't be applied to the bill for that hospital stay.
Alternate Methods of Treatment - There are certain types of procedures which can be performed or conditions which can be treated other than in a hospital. In such a case, MCM will discuss alternatives to hospital confinement with the patient and doctor. They may also be able to identify possible resources in your area that can provide the alternative care.
Benefits are also payable for hospice care. The hospice care program provides coverage for certain types of services not normally covered under the Plan and allows a terminally ill person to remain primarily at home instead of having to stay in the hospital.