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Medical Management & Utilization Review

CareAllies/Intracorp performs medical management services and utilization for the Plan.

Utilization review is a process to make sure that the care you receive is medically necessary, delivered in the most appropriate location, and follows generally accepted medical standards. Utilization review provides clinical review and certification of the medical necessity of care. Certification of medical necessity does not guarantee that services are covered. Benefits are subject to the patient's eligibility at the time charges are actually incurred, and to all other terms, conditions, and exclusions of the Plan. 

 

The following services require certification by CareAllies/Intracorp.

  • Inpatient Hospital Admissions
  • Outpatient CAT Scan
  • Outpatient MRI Scan
  • Private Duty and Home Health Nursing
  • Solid Organ and Bone Marrow/Stem Cell Transplants
  • Home Infusion Therapy
  • Skilled Nursing Facility
  • Long Term Care Acute Care Facility
  • Hospice Care Services
  • Wound Vacuum Assisted Closure

Notification Requirements


It is the participant's responsibility to make sure that CareAllies/Intracorp is notified in advance of certain types of medical services. The notification requirements that apply to inpatient hospital admissions and specified outpatient diagnostic tests are detailed below.

Private duty and home health nursing services, solid organ and bone marrow/stem cell transplants, home infusion therapy services, Skilled Nursing Facility admissions, Long Term Care Facility admissions, Hospice Care Services, and Wound Vacuum Assisted Closure must be certified as medically necessary by CareAllies/Intracorp.

CareAllies/Intracorp must be contacted in advance of any anticipated non-emergency hospital admissions and immediately following an emergency admission by calling 1-800-523-8739. Failure to comply with notication requirements will result in financial penalities, reduction of benefits, or denial of benefits.

 

 Inpatient Hospital Admissions:

For certification review of non-emergency admissions to a hospital or psychiatric or chemical dependency facility, you are required to call CareAllies/Intracorp at 1-800-523-8739 as soon as you are advised that your or your covered dependent may need to be hospitalized. In all cases, the call must be made as soon as possible but at least 5 days before the admission date. It is your responsibility to ensure that notification requirements are met. Intracorp will provide you a confirmation number once certification has been given.


Emergency Hospital Admission

When certifying an emergency hospital admission, CareAllies/Intracorp must be notified within 48 hours of emergency admission to a hospital. If the participant is unable to make the call, another party can make the call on the participant's behalf. However, it is the participant's responsibility to ensure that notification requirements are met.

Maternity Care and Hospitalization

There is an exception to the 5-day advance notification rule for maternity care. Because of the need to ensure that maternity cases receive the proper case management, CareAllies/Intracorp should be contacted:

  • as soon as a pregnancy is confirmed, and no later than the 4th month of pregnancy, and
  • within 48 hours of admission for delivery
CareAllies/Intracorp must also be contacted in the following instances:

  • if the newborn requires additional hospital days beyond the mother's length of stay, or
  • if the mother is not a Plan participant but the child will be enrolled in the Plan.


Notification Requirements for Inpatient Hospital Admissions

Type of Admission

Notification Requirement

Non-Emergency As soon as possible, but at least 5 days prior to admission
Maternity Within 48 hours of admission
Emergency Within 48 hours of admission

 

Please see the Summary Plan Description (page 36) for listing of Inpatient Financial Penalties for failure to meet the notification requirements.

 

Outpatient Diagnostic Tests

The following outpatient services will require pre-certification by CareAllies prior to services being rendered:

  • CAT Scan – visual x-ray of soft tissue/bone; specialized x-ray visualization of the body structures
  • MRI Scan – magnetic imaging of body structures

 


Notification Requirements for Outpatient Diagnostic Tests

Non-Emergency

 As soon as possible, but at least 48 hours prior to procedure being performed
Emergency Within 48 hours of procedure being performed

Notification that occurs any time notice is given to Intracorp 48 hours after the procedure is performed, a $100 penalty will be imposed if the outpatient service is deemed medically necessary.

Failure to comply with certification requirements will result in financial penalties, reduction of benefits, or denial of benefits. Certification determination does not guarantee either payment of benefits or the amount of benefits that will be paid. Eligibility for and payment of benefits are subject to all terms, conditions, and limitations of the Plan.

 

CareAllies
3567 Parkway Lane, Suite 200
Norcross, GA 30092
1-800-523-8739

This page is maintained by Lisa Giger. Send questions and comments regarding this site to lgiger@deltastate.edu

 

 

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