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Medical Benefits - Calling for Pre-authorization
 

The Plan will only cover procedures and treatments that are medically necessary.  Pre-authorization is a medical review by an independent group of physicians to determine whether a procedure or treatment is medically necessary.  The Plan has contracted with HealthCare Strategies to perform this function. 

All inpatient hospital stays and the following outpatient procedures must be pre-authorized by HealthCare Strategies:

• Bariatric Surgery (surgery to treat obesity)

• Bletharoplasty

• Botox Injection

• Breast Surgery

• CT Scan for Virtual Colonoscopy

• Durable Medical Equipment over $1,500

• Home Health Care

• Home Infusion Therapy

• Lithrotripsy

• Panniculectomy

• Varicose Veins, stripping, ligation and sclerotherapy

The Plan also requests that maternity stays be pre-authorized as soon as practical. 

To pre-authorize your procedure, have your physician or health care provider call HealthCare Strategies at 1-800-582-1535.

Payment for your claim will be denied should you have one the procedures listed above and fail to pre-authorize the procedure.  You may retroactively obtain certification for the procedure after it has been performed; however,  there is a fee for retro-certification which you must pay.  If your claim is determined to have been medically necessary, payment will reduced by 50% after application of the usual plan provisions. 

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