Health Care
Medical (2009)
Pre-Certification of Medical Benefits
Pre-certification of medical care in Kraft Network and Out-of-Area Plans
will help protect you physically and financially. By calling Member Services,
you can confirm the procedure is medically necessary and eliminate the penalty for
not pre-certifying certain care.
When to Call
You, your doctor, the hospital, a family member or friend must call Member Services
to pre-certify the following procedures or situations:
Within 48 hours after an emergency hospital admission
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Before a scheduled hospital admission (including inpatient mental health or substance abuse care) or organ transplant
Before admission to a skilled nursing facility or rehabilitation facility
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Before use of home health care, hospice care or private duty nursing.
Although pre-certification is not required for outpatient surgery, it is recommended.
If you are unsure as to whether pre-certification is necessary, we strongly encourage
you to call to have peace of mind and to make an informed decision about your care.
When you call to pre-certify a transplant, you will also have access to the
plan’s Center of Excellence network. All centers are selected based on a
proven history of successful outcomes, overall experience with the procedure being performed
and recognized delivery of care to transplant patients. If you choose a Center of Excellence
far from your home, you and a family member may also be eligible for travel and lodging benefits.
Call Member Services for details.
What You Pay if You Don’t Pre-Certify
It is the employee or patient's responsibility to make sure that pre-certification is
secured. Your ID card has the appropriate telephone number to call
for pre-certification.
If you don’t call Member Services to pre-certify services:
You will pay a $300 penalty, which does not apply to the annual deductible
or annual out-of pocket maximum.
If the care is not determined to be medically necessary, it will not be covered by the plan.
If you stay in the hospital beyond the approved period, those days are not covered (you pay 100%).
If your doctor recommends a stay beyond the approved days, Member Services will review the additional
information with your doctor to determine if the additional days are medically necessary.
For more information, see Plan Details.
Also consider …
Verifying Coverage for a Procedure/Treatment