Managing Your Care
We work hard to manage costs while protecting the quality of care. Our team of nurses and social workers review three aspects of medical care:
- Is the care setting appropriate?
- Are the services medically necessary?
- Is the length of time spent in the hospital appropriate?
So how does this benefit you? By making sure your care is provided in the most appropriate manner, we can lower medical expenses for everyone and maintain reasonable premium rates.
Approval for Services
You may need approval from us for certain services—this is called preauthorization. If preauthorization is not obtained when required, your benefits may be reduced or denied. Preauthorization is needed prior to receiving many services and medications. However, in some cases we may perform a post-service review to determine coverage. Preauthorization can take up to two weeks to process, though exceptions may apply for emergency care.
To see a list of all services that require preauthorization, call Member Services or see your member materials.
Request for Additional Services
If you request more services—in addition to those already approved—we'll work with your doctor and the facility staff to make sure that care is received in an appropriate setting. This is called a concurrent review. We will help the facility caregivers plan for your transition home or to another care setting.