Pre

Pre-Authorization of Benefits Required:

The purpose of Pre-Authorization is to help control the costs of health care to the Subscriber and to the Plan. The requirement to obtain pre-authorization of the following devices, care or drugs should not be interpreted to create a pre-service claim for the purposes of the claims procedures.

Certain devices, supplies and equipment. Prosthetic devices, durable medical equipment (rental or purchase) costing five hundred ($500) dollars or more including, but not limited to, wheelchairs (rental or purchase), scooters (rental or purchase), hospital beds and/or special mattresses, continuous airway pressure devices and renal or diabetic supplies, must be pre-authorized. ACS has contracts with various companies for covered devices, supplies and equipment, so when pre-authorization is obtained, costs to the Subscriber and to the Plan may be reduced.

Certain care and therapy. Care involving dialysis, home health care/visits, hospice, skilled nursing care, inpatient rehabilitation, outpatient pulmonary and cardiac rehabilitation, must be pre-authorized. Eligible charges for medically necessary drugs, injectables, supplies that are dispensed in a physicianís office or administered by or under the supervision of a licensed professional in an appropriate setting will be limited to the average wholesale price in the most current edition of Red Book, plus twenty percent (20%), even if the provider is in the Plan's preferred provider organization. ACS has a contract with BioScrip (www.scripsolutions.com) for covered chemotherapy drugs and other infusion therapy drugs, so when pre-authorization is obtained, costs to the Subscriber and to the Plan may be reduced.

Failure to obtain the required pre-authorization detailed above will result in a retrospective review of the care, therapy, devices, or drugs provided and may result in a determination that the care, therapy, devices, or drugs are not medically necessary, or that the charges exceed the usual, reasonable and customary charges allowed by the Plan, or that said care, therapy, devices, or drugs are not covered by the Plan. Although the rendering provider normally will obtain pre-authorization, it is the Member's ultimate responsibility to ensure pre-authorization of the above benefits. If care, therapy, devises or drugs are not pre-authorized and a portion of the charges are not covered by the Plan for a reason set out in this paragraph, the Participant could be billed for the balance of the charges by the provider. Pre-authorization may be obtained by telephoning the number on your ACS Identification Card.

DOCTORS DIRECT HEALTHCARE:

Some plans administered by ACS have made arrangements with Doctors Direct Healthcare to provide Medical Management services to all covered persons at no cost to Participants. Medical Management includes: prior approval of planned inpatient admissions, outpatient surgeries and certain outpatient services; prompt notification of emergency admissions; disease management and maternity management. Please see the chart that follows for a list of admissions and procedures that must be Pre-Certified. Failure to obtain prior approval of a listed admission or procedure could result in a reduction of coverage.

Doctors Direct Healthcare will provide management services for diabetes, asthma, cardiovascular disease, hypertension, and hyperlipidemia. These illnesses require continued medical care and education in order to reduce the risk of long term complications. If you have been diagnosed with one of these conditions, you will be contacted about enrolling in the program. Participants in the program may qualify for reduced prescription drug copays for disease specific medications and free glucose or blood pressure monitors. If you have any questions about the disease management services of Doctors Direct Healthcare, please call the telephone number on your ACS ID card.

Doctors Direct Healthcare also has a voluntary maternity management program for pregnant covered employees and covered spouses. This is a program designed to help you avoid the medical complications, health risks and expenses associated with premature birth. Call Doctors Direct toll free at the telephone number on your ACS ID card once you know you are pregnant. If you are identified at risk for premature delivery, a registered nurse will be assigned to your case to work with you and your doctor directly throughout your pregnancy. Doctors Direct Healthcare will contact you by phone and send informational material by mail. Regardless of your risk for premature delivery, Doctors Direct Healthcare will send you a packet of information to help with your pregnancy. The goal is to ensure the best outcome for you and your baby as you follow your physician’s plan of care.

In addition to the references and resources listed under Benefits Processing Guides, Doctors Direct Healthcare will also use for Utilization Management purposes: the Sandhills Physicians, Inc. Clinical Guidelines and Durable Medical Equipment Formulary; the Interqual ISP Indication for Surgical Procedures and Interqual ISD-AC Indications for Intensity of Service, Severity of Illness and Discharge Screens for Inpatient Care; the Medicare Part B, North Carolina, Local Medical Review Policy; the APTA Guide to Physical Therapy Practice; and the on-line version of the American College of Radiology Appropriateness Criteria.

DOCTORS DIRECT PRE-CERTIFICATION REQUIREMENTS

BENEFITS AND SERVICES UM REQUIREMENTS (When medically necessary)
INPATIENT ADMISSIONS (Non-Emergency) Includes Medical, Mental Health, Chemical Dependency and Rehabilitation	Pre-Certification Required. (If not obtained, benefits will be reduced or denied per SPD and an additional deductible may apply).
INPATIENT ADMISSIONS (Emergency) Includes Medical, Mental Health and Chemical Dependency	Pre-Certification Required within 72 hours after admission. (If not notified, benefits will be reduced or denied per SPD and an additional deductible may apply).
SURGERY--OUTPATIENT	Pre-Certification Required. (If not obtained, benefits will be reduced or denied per SPD and an additional deductible may apply).
SKILLED NURSING FACILITY CARE	Pre-Certification Required. (If not obtained within the first 72 hours of admission, benefits will be reduced or denied per SPD and an additional deductible may apply).
TRANSPLANTS	Pre-Certification Required.
OTHER SERVICES: Home Health, Hospice Home Infusion Therapy Physical Therapy (after initial evaluation) Occupational Therapy (after initial evaluation) Speech Therapy (after initial evaluation) Cardiac Rehab (after initial evaluation) Pulmonary Rehab (after initial evaluation) Adult MRI's (17yo and older) PET Scan Sonorex/OssaTron Therapy Reconstructive/Plastic Surgery Durable Medical Equipment Orthotics & Prosthetics Dialysis Chemotherapy	Pre-Certification Required. (If not obtained, benefits will be reduced or denied per SPD and an additional deductible may apply). (DME/Medical Supplies/Orthotics & Prosthetics: Pre-Certification is required for all rentals. Purchases over a specified amount may also require Pre-Certification.) Please note—Diabetic Supplies do not require pre-certification with the exception of Insulin Pumps.

Home

[Updated 08/27/2008]