Health Benefits and Claims
Do I need to call for Pre-Certification for an MRI & Other Diagnostic Imaging Tests?
Your medical identification card gives you a Pre-certification telephone number to call your Cost Containment Administrator for Diagnostic Imaging Review. Diagnostic Imaging Review means review by the Cost Containment Administrator of a Physician’s report demonstrating the need for the Diagnostic Imaging. Outpatient Diagnostic Imaging includes, but is not limited to, MRI, MRA, PET, CT and SPECT imaging tests. Benefits payable for Outpatient Diagnostic Imaging will be reduced by 25% unless: (1) an Outpatient Diagnostic Imaging review is requested by you, or a family member, or a Physician and approved by the Cost Containment Administrator. (2) for services beyond the original approval, the Outpatient Diagnostic Imaging review is ex-tended and approved by the Pre-certification Administrator. The request must be prior to, but no later than, the day of testing by an Outpatient Diagnostic Office or Facility (for other than a Medical Emergency). If an Outpatient Diagnostic Imaging review is not requested prior to testing as specified above, the 25% reduction in benefits payable will be applied. Benefits will be payable only for that part of the Outpatient Diagnostic Imaging charges that have been approved by the Cost Containment Administrator and that We determine to be Covered Charges. The 25% reduction in benefits payable is a penalty for failure to comply with the Utilization Management Requirements listed. The reduction: (1) will not count toward satisfaction of the Out-of-Pocket Expense limits; and (2) will not exceed $300 per occurrence for any one person.
<< Back to FAQs