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.
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.
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.
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
Type of Admission
|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:
Notification Requirements for Outpatient Diagnostic Tests
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.
3567 Parkway Lane, Suite 200
Norcross, GA 30092
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