MCW Health Plan Prior Authorization Requirements and Procedures

IMPORTANT: Please be aware that if the required Prior Authorization is not obtained before services are rendered, this means that the Participant may need to:

• Pay the full cost of medical services.
• Pay a penalty in the amount of $100.

SERVICES WHERE PRIOR AUTHORIZATION IS REQUIRED*:

1. Non-Emergency Inpatient Services

• Inpatient Maternity (delivery and newborn services exceeding a two (2) day stay for Vaginal Delivery and four (4) day stay for Cesarean section Delivery)
• All Hospital Inpatient services, including observation (if member requires more than 23 hours of observation) and Rehabilitation Services, excluding inpatient maternity as provided above
• Skilled Nursing Facility/Extended Care Facility
• Residential Treatment
• All organ transplant services including evaluation

2. Ambulance and Air Transports

• Ambulance (ground) – Transportation by professional ambulance, including approved available train transportation, to a local hospital or transfer to the nearest facility having the capability to treat the condition, if the transportation is connected with an inpatient confinement.

• Ambulance (air/flight) – Inter-facility patient transport by air transport, for covered persons if there is a life threatening situation or it is deemed to be medically necessary.

Post-Medical Emergency Travel Assistance (100+ miles from home): Call Assist America at 1 (800) 872-1414

All other situations: All flight-based inter-facility patient transport services require pre-authorization from the Plan Administrator via Sentinel Air Medical Alliance, LLC. Please contact Sentinel at 1 (877) 542-8828

• Sentinel may discuss with the physician and/or hospital/facility the diagnosis and the need for inter-facility patient transport versus alternatives.
• Failure to notify Sentinel Air Medical Alliance, LLC and subsequently obtain a pre-authorization number from Sentinel may, solely in the Plan Administrator’s discretion, result in a reduction or denial of benefits for charges arising from or related to inter-facility patient transport via air/flight.  Non-compliance penalties imposed for failure to notify Sentinel will not be included as part of the annual total out of pocket expense maximum.
• The Plan Administrator retains the discretionary authority to limit benefit availability to alternative Providers of flight-based inter-facility patient transport if and when a Provider fails to comply with the terms of the Plan, or proposed charges exceed the Maximum Allowable Charge in accordance with the terms of the Plan.

3. Durable Medical Equipment Costing More than $1,000

Examples of Durable Medical Equipment items that UMR needs to be contacted regarding: hearing aids, continuous and other passive motion devices, power wheelchairs, customized manual wheelchairs, customized electric wheelchairs and other customized motorized devices, wheelchair accessories including power joystick control, power tiller control, power seat tilt, power seat recline and power leg elevation, scooters, roll about walking aids, hospital beds, mattresses, feeding pumps, lymphedema pumps, INR devices, cardio/chest compression vests, ventilators, electrical stimulation devices (spinal, neuromuscular, bone growth, etc.), cranial orthotics (molding helmets), patient lifts, seat lifts, home dialysis equipment, home hyperbaric units, Mobile Cardiac Outpatient Telemetry- MCOT (outpatient heart monitoring) and communication devices.

Note: The prior authorization requirement does not apply to reoccurring supplies (ex: sensors for diabetics).

4. Bariatric Surgery Services

No benefits are payable if bariatric surgery services are not pre-authorized prior to initiation of services. Benefits for bariatric surgery services are available to employees and their dependents only after the employee completes two (2) years of consecutive employment in the most recent employment period.

5. Outpatient Dialysis**

6. Home Health Infusion Therapy**

7. Transgender Surgery

No benefits are payable if transgender surgery services are not authorized prior to initiation of services.

8. Genetic Testing (other than for BRCA1 testing, BRCA2 testing and Amniocentesis – which will be reviewed for Medical Necessity at point of claim).

9. MRI Imaging (selected procedures when performed on a non-emergency basis)

Prior Authorization requirement is waived if service is provided at The Medical College of Wisconsin, Froedtert Health, Froedtert Menomonee Falls Hospital or Froedtert West Bend Hospital. In addition, if the MRI/CT is ordered by a physician of the Medical College of Wisconsin but performed at a different facility/site, the prior authorization will be waived.

10. CT Scanning (selected procedures when performed on a non-emergency basis)

Prior Authorization requirement is waived if service is provided at The Medical College of Wisconsin, Froedtert Health, Froedtert Menomonee Falls Hospital or Froedtert West Bend Hospital. In addition, if the MRI/CT is ordered by a physician of the Medical College of Wisconsin but performed at a different facility/site, the prior authorization will be waived.

11. Participation in Phase II or III Clinical Trials

12. Selected Outpatient Surgeries

• Reduction Mammoplasty
• Nasal Surgery
• Maxillofacial Surgery
• Varicose Vein Procedures
• Blepharoplasty
• Uvulopalatoplasty (including laser assisted)
• Other Cosmetic Surgeries

SERVICES WHERE PRIOR AUTHORIZATION IS RECOMMENDED**

1. Neuropsychological Testing
2. Intensive Outpatient Program (IOP)
3. Partial Hospitalization Program (PHP)

*If the covered person (or authorized representative) fails to contact UMR Care prior to the initiative of services and within the timelines detailed above, there will be a one hundred dollar ($100) penalty (except as specified herein); which will not count toward satisfaction of the calendar year out of pocket maximum.

**Penalty does not apply.

Procedure for Requesting Prior Authorization for Non-Emergency Situations

The Participant or the Participant’s Provider should contact UMR Care on behalf of the Plan at the Prior Authorization phone number listed on the Participant’s Identification Card. A request for Prior Authorization should be made at least fourteen (14) business days prior to rendering the service.

UMR Care will review the request and determine whether the service is a Covered Expense. UMR Care will furnish written or verbal notice of its decision to the Participant and/or Provider as appropriate, as soon as reasonably possible given the medical circumstances.

Procedure for Emergency or Urgent Situations

The Plan does not require Prior Authorization for an Emergency Medical Condition, or for Urgent Care Services, however the Participant or Authorized Representative should notify UMR Care of the situation no later than 48 hours after receiving services and being stabilized, or the next business day, whichever is later.

Note: The Prior Authorization provision will be waived by UMR if the covered expense is rendered/provided outside of the continental United States of America or any U.S. Commonwealth, Territory or Possession.

The Plan cannot review or give Prior Authorization for coverage outside of the Plan’s current Plan Year. Prior Authorization does not verify eligibility for benefits nor guarantee benefit payments under the Plan. It is the Participant’s responsibility to verify that the above services have been granted Prior Authorization before the services are provided.