Out-Patient Hospitalization

Please note: the information on this page is provided as a basic reference and should not be considered all-inclusive. Please refer to your Member Guide or benefit plan for complete details.

Outpatient Surgery
To obtain the highest level of benefits for an out-patient hospitalization, it's important to follow the requirements stipulated by your policy. Before your next out-patient hospitalization, make sure to verify the following information.

Check into the following:

• What hospitals are part of your plan network? (Visit Find a Doctor to assist you).
• Will needed followup care, such as nursing home or home health care, be covered by the plan?
• If I have a serious medical problem, will my plan provide someone to oversee care and make sure my needs are met?
• See the back of your Member ID card for a quick summary of when to call along with the necessary phone numbers. Member Services is available at 1-888-915-4001 to answer questions to determine if and how services are covered under your benefit plan.
• Understand how your benefit plan handles getting a second doctor's opinion on whether surgery or another treatment is needed. Are second opinions encouraged or required? Who pays?

Preauthorization
Preauthorization is a review process which takes place during out-patient service situations, they're enacted according to the requirements of your policy or can be enacted at your request.

A team of medical professionals review preauthorizations. They determine if your proposed service is covered in your benefit plan, and if it's medically necessary (as per your plan's definition) for your care.

Before deciding a course of action on a particular out-patient medical service, please check your benefit plan and determine if any preauthorizations are required prior to proceeding.

Below are some examples of medical services for which preauthorizations are strongly encouraged:

• Durable medical equipment and rentals exceeding $500 (Equipment that is ordered by a doctor for use in the home. These items must be reusable, such as walkers, wheelchairs, or hospital beds).
• Any surgery that ends in “plasty” (e.g., mammoplasty, gastroplasty).
• Sleep studies, polysomnograms for assessment of obstructive sleep apnea.
• Excision or ligation of varicose veins.
• Transplants/implants of body organs, tissue-to-tissue exclusion.
• New medical or biomedical technology (e.g., Positron Emission Tomography (PET) scans).
• Sticky glue into uterine arteries.
• All injections for pain management (e.g., epidurals or facet injections).

To request a preauthorization, fax your request to 1-608-226-4777 or call 1-800-333-5003.