|
|
|
|
|
UFCW LOCAL 1776 and
PARTICIPATING EMPLOYERS HEALTH and WELFARE FUND |
|
| Pre-certification |
You are not required to take any action to pre-certify a hospital admission or
services provided or referred by your PCP.
Your provider will take care of pre-certification for you.
When you self-refer to a hospital or
provider, however, you must notify the KPOS Program to pre-certify the
admissions or services. Admissions or
services requiring prior authorization include: all non-emergency hospital admissions; midwife/birthing facility; home health care; skilled nursing facility; psychiatric, substance abuse and
alcohol treatment; private duty nursing services; and durable medical equipment costing over
$1,500. |
|
Call for Pre-Certification Patient Care Management 1-800-227-3116 In Philadelphia: 215-567-3070 |
|
How it works The pre-certification staff includes nurses, doctors and other medical professionals who compare the information about your condition with nationally accepted medical standards. The KPOS Program representative will also talk with your doctor, hospital or other provider. Then, the representative will call you to confirm the medical necessity of your treatment. If you would like another opinion about whether a recommended surgery is necessary, the representative will help you obtain a second surgical opinion. If a hospital stay is necessary, the KPOS Program will approve the length of stay that will be covered. This way, you know whether your treatment is covered and to what extent. You can use this valuable information to make a better-informed decision. Pre-certification for maximum benefits If the pre-certification procedures are not followed, as listed above, self-referred benefits under the KPOS Program will be reduced or not paid at all. If the admission or other services are later determined to have been medically necessary, benefits for eligible inpatient charges will be reduced by $700 for failure to pre-certify. However, benefits will not be paid if the KPOS Program later determines that the admission or other services were not medically necessary. The same penalties apply for charges for any length of stay beyond what has been pre-certified by the KPOS Program for that admission. Claim filing If you use services provided or referred by your PCP, you usually do not have to file a claim. The provider will generally do it for you. If you self-refer to a hospital or provider, or in the case of emergency or urgent care, you may have to submit your claim to the KPOS Program. You should always bring your KPOS Program I.D. card with you. You may have to pay for the expense and then file your claim for reimbursement. Lifetime maximum benefits There is no lifetime maximum to benefits under the KPOS Program when you use referred services and providers. Lifetime benefits for self-referred care are limited to $1,000,000 per person. Benefits paid under the Fund for mental, nervous, drug and alcohol disorders will be applied toward this lifetime maximum for self-referred care. |
|
Keystone Point of
Service Plan | ||
| Plan Feature | Referred (In-Network) | Self-Referred (In and Out-of-Network) |
| Calendar Year Deductible | None |
$500 per person $1,500 per family |
| Calendar Year Out-of-Pocket Maximum (not including deductible) | $1,000 per person $2,000 per family |
$2,500 per person $7,500 per family |
| Lifetime Maximum | None | $1,000,000 |
| Doctor's Visits Primary Care | $15 co-pay | 80% of reasonable and customary amount after deductible |
| Specialist | $25 co-pay | 80% of reasonable and customary amount after deductible |
| Routine Adult Physicals | $15 co-pay | Not covered |
| Routine Gynecological | $25 co-pay (no referral necessary) | 80% no deductible |
| Routine Mammogram Routine Pap Smear | 100% | 80% no deductible |
| Well Child Care/ Immunizations | $15 co-pay | 80% no deductible |
| Hospital (semi-private room) | 100% | 80% of reasonable and customary amount after deductible * |
|
Keystone Point of
Service Plan | ||
| Plan Feature | Referred (In-Network) | Self-Referred (In and Out-of-Network) |
| Surgery | 100% | 80% of reasonable and customary amount after deductible * |
| X-ray and Lab | 100% | 80% of reasonable and customary amount after deductible * |
| Maternity Care | $25 co-pay first visit only; then 100% ( no referral necessary for routine maternity care) | 80% of reasonable and customary amount after deductible |
| Hospital Emergency Room Care | $35 co-pay (waived if admitted) | $35 co-pay (waived if admitted) |
| Skilled Nursing Facility (custodial care not covered) | 100% up to 180 day | 80% of reasonable and customary amount after deductible * |
| Mental Health Impatient | 100% up to 35 days/year | 80% of reasonable and customary amount after deductible * |
| Outpatient | $25 co-pay per visit up to 20 visit per year | 50% of reasonable and customary amount after deductible up to 60 visits per year/$30 maximum per visit |
| Substance Abuse Inpatient | 100% up to 35 days/year | 80% of reasonable and customary amount after deductible* |
| Outpatient | $25 co-pay up to 60 visits per year | 80% of reasonable and customary amount after deductible up to 30 visits per years* |
| *pre-certification required | ||