Some of the benefits provided to you through the OU Health Plan are coordinated by managed benefit
coordinators that encourage the efficient and effective use of hospital, surgical, physical medicine, mental
health and substance abuse services. This section is meant to inform you about the managed benefits
program and alert you to the instances in which you are required to contact a managed benefits
coordinator so that your plan benefits are not reduced or disallowed. Make sure to review Sections 9 and
10 for additional information on the Managed Benefits Program.
Your Responsibilities Under the Managed Benefits Program. It is important for you to remember that this Plan contains a managed benefits component that requires you to notify the appropriate managed benefits coordinator prior to hospital admission or utilization of certain services. If you fail to notify the managed benefits coordinator when required, your plan benefits may be reduced or even disallowed. Names and contact information for managed benefit coordinators are found in Appendix A of this document. If you are going to receive any of the services described below, you must call the appropriate coordinator for pre-approval of care. Those services that require a phone call to the appropriate managed benefits coordinator are listed below:
- Hospital Admissions: If you intend to be hospitalized for an elective inpatient admission, you must receive approval at least five working days prior to admission. (Emergency, urgent, and maternity admissions do not require pre-approval; however, notification of such admission must be made within 48 hours after admission, or as soon
as reasonably possible.)
If you fail to notify the managed benefits coordinator of your hospitalization, your benefits may be significantly reduced or even disallowed.
- Skilled Nursing Facility Admissions, Home Health Care Visits, Hospice Care Programs. If a patient is not currently hospitalized, he (or someone on his behalf) must notify the appropriate coordinator at least five working days prior to admission to a Skilled Nursing Facility or of the beginning of home care or hospice visits.
If you fail to notify the managed benefits coordinator of your admission or the beginning of home care or hospice visits, your benefits may be significantly reduced or even disallowed.
- Mental/Nervous Disorders and Substance Abuse Treatment: All inpatient admissions for treatment of mental and nervous disorders or substance abuse require pre-approval five (5) working days prior to a scheduled admission, or within two (2) working days after an emergency admission, or as soon as reasonably possible. (For outpatient treatment, authorization for additional visits must be obtained from the coordinator prior to the fourth outpatient visit.)
If you fail to notify the managed benefits coordinator of your admission or treatments, your benefits may be significantly reduced or even disallowed.
- Chiropractic Care, Physical and/or Occupational Therapy, Physical Medicine Services. If you are going to receive out-of-network chiropractic care, physical therapy, occupational therapy or other physical medicine services, please notify the appropriate managed benefits coordinator to be certain the services are covered. (If services are
from in-network providers, the provider will contact the coordinator.)
If you fail to notify the managed benefits coordinator of your admission or treatments, your benefits may be significantly reduced or even disallowed .
- Mandatory Second Surgical Opinion Program. Prior to having certain elective surgical procedures performed, you must obtain a second opinion in order to receive full benefits under this Plan. To find out if the procedure you have planned requires a second opinion, call the coordinator at least 14 days prior to the scheduled procedure. Some
examples of non-emergency surgeries that always require a second opinion include but are not limited to the following: gastric bypass; hysterectomy; joint replacement; laminectomy; spinal fusion.
If you fail to notify the managed benefits coordinator or if you do not obtain a required second opinion, your benefits may be significantly reduced or even disallowed.
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Large Case Management Program. Sometimes a medical situation is identified that may result in
unusually large claims to the health plan (for example, multiple or premature births, brain injury, chronic
neurological diseases, eating disorders, etc.). If such a catastrophic disease or injury occurs, the managed benefits coordinator may work with the patient’s attending physician to provide a long-term plan of care. In addition, and if approved by the appropriate managed benefits coordinator, the patient may be eligible for alternative health benefits that might otherwise not be available under the Plan. |
