2021 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 36
MEDICAL MANAGEMENT AND PRECERTIFICATION PROGRAM
You, your eligible Dependents or a representative acting on your behalf must call the Medical Management and
Precertification Program Administrator to receive certification of inpatient admissions, as well as other non-Medical
Emergency services listed below. This call must be made at least 24 hours in advance of inpatient admissions or
receipt of the non-Medical Emergency services identified below; or within 72 hours, or if later, by the next business
day after a Medical Emergency inpatient admission. Failure to obtain precertification or notify the Medical
Management and Precertification Program Administrator within the time frame indicated above may result in eligible
expenses being reduced or denied. Please refer to the penalty section below.
Meritain Health Medical Management/Precertification: 866-405-2021
Meritain Health Nurse line: 888-229-9301
Medical Management/Precertification is a program designed to help ensure that you receive necessary and
appropriate healthcare while avoiding unnecessary expenses. The program consists of:
Precertification of Medical Necessity. The following items and/or services must be precertified before any
medical services are provided:
Chemotherapy - all settings including services rendered in a Physician’s office;
Inpatient admissions, including inpatient admissions to a Skilled Nursing Facility, Extended Care
Facility, Rehabilitation Facility, and inpatient admissions due to a Mental Disorder;
Radiation therapy - all settings including services rendered in a Physician’s office; or
Concurrent Review for continued length of stay and assistance with discharge planning activities.
Medical Management/Precertification Does Not Guarantee Payment
All benefits/payments are subject to the patient’s eligibility for benefits under the Plan. For benefit payment, services
rendered must be considered an eligible expense under the Plan and are subject to all other provisions of the Plan.
This program is not designed to be the practice of medicine or to be a substitute for the medical judgment of the
attending Physician or other healthcare provider.
How the Program Works
Before you or your eligible Dependents are admitted to a medical facility or receive items or services that
require precertification on a non-Medical Emergency basis (that is, a Medical Emergency is not involved), the
Medical Management and Precertification Program Administrator will, based on clinical information from the
provider or facility, certify the care according to the Medical Management and Precertification Program
Administrator’s policies and procedures.
The Medical Management and Precertification Program is set in motion by a telephone call from you, the patient or
a representative acting on your behalf or on behalf of the patient.
To allow for adequate processing of the request, contact the Medical Management and Precertification Program
Administrator at least 24 hours before receiving any item or service that requires precertification or an inpatient
admission for a Non-Medical Emergency with the following information:
Name, identification number and date of birth of the patient;
The relationship of the patient to the Covered Employee;
Name, identification number, address and telephone number of the Covered Employee;