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Medical Management and Utilization Review

Intracorp performs medical management services and utilization review for the Plan.

Utilization review is a process to make sure that the care participants 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 Intracorp:

Inpatient hospital admission Outpatient CAT Scan Outpatient Colonoscopy Outpatient MRI Scan Outpatient UGI Endoscopy/EGD Private duty and home health nursing services Solid organ and bone marrow/stem cell transplants Home infusion therapy services

Notification Requirements It is the participant’s responsibility to make sure that 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 within this section.

Private duty and home health nursing services, solid organ and bone marrow/stem cell transplants, and home infusion therapy services must be certified as medically necessary by Intracorp. See the Covered Services section for more information on these services.

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

Note: Certification is not required for those participants having Medicare or other primary coverage, unless the service is not covered by the primary coverage. In this case, the service will be subject to the certification process.

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