2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 37
(4)
Name of Employer and group number;
(5)
Name, address, Tax ID # and telephone number of the admitting Physician;
(6)
Name, address, Tax ID # and telephone number of the medical facility with the proposed date of admission
and proposed length of stay;
(7)
Proposed treatment plan; and
(8)
Diagnosis and/or admitting diagnosis.
If there is an inpatient admission with respect to a Medical Emergency, you, the patient or a representative acting
on your behalf or on behalf of the patient, including, but not limited to, the Hospital or admitting Physician, must
contact the Medical Management and Precertification Program Administrator within 72 hours after the start of the
confinement or on the next business day, whichever is later.
Hospital stays in connection with childbirth for either the mother or newborn may not be less than 48 hours following
a vaginal delivery or 96 hours following a cesarean section. These requirements can only be waived by the
attending Physician in consultation with the mother.
You, the patient and the providers are NOT REQUIRED to obtain precertification for a maternity delivery admission,
unless the stay extends past the applicable 48- or 96-hour stay. A Hospital stay begins at the time of delivery or for
deliveries outside the Hospital, the time the newborn or mother is admitted to a Hospital following birth, in connection
with childbirth. If a newborn remains hospitalized beyond the time frames specified above, the confinement must
be precertified with the Medical Management and Precertification Program Administrator or a penalty will be
applied.
The Medical Management and Precertification Program Administrator, in coordination with the facility and/or
provider, will make a determination on the number of days certified based on the Medical Management and
Precertification Program Administrator’s policies, procedures and guidelines. If the confinement will last longer than
the number of days certified, a representative of the Physician or the facility must call the Medical Management and
Precertification Program Administrator before those extra days begin and obtain certification for the additional time.
If the additional days are not requested and certified, room and board expenses will not be payable for any days
beyond those certified.
If the patient does not obtain precertification for their inpatient admission at least 24 hours in advance of the
admission or notify the Medical Management and Precertification Program Administrator within 72 hours after a
Medical Emergency admission or if precertification is obtained or notification received outside the time frames
specified, eligible expenses may be reduced or denied. Please refer to the penalty section below.
Penalty
If you fail to obtain precertification or fail to notify the Medical Management and Precertification Program
Administrator within the time periods described above, benefits under the Medical Plan will be reduced by $500 per
occurrence and this penalty amount will not accumulate toward any Out-of-Pocket Maximum limit. Please note that
this penalty will not apply if the patient’s hospital stay is less than 24 hours.
Discharge Planning
Discharge planning needs are part of the Medical Management and Precertification Program. The Medical
Management and Precertification Program Administrator will assist and coordinate the initial implementation of any
services the patient will need post hospitalization with the attending Physician and the facility. If the attending
Physician feels that it is Medically Necessary for a patient to stay in the medical care facility for a greater length of
time than has been precertified, the attending Physician or the medical facility must request the additional service
or days.
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