Pre-certification

If you fail to follow the procedures for pre-certification when you use a BlueCard PPO provider or non-preferred provider, Personal Choice will reduce its benefit payment by $1,000 for all inpatient hospital admissions and 20% for all other services that require pre-certification.

Personal Choice must approve certain services as medically necessary before you receive treatment. This is called pre-certification. Please refer to the chart that lists the services requiring pre-certification, as well as the section titled "What the Plan Covers" for more information. When a Personal Choice preferred provider recommends that you or an eligible dependent use the services listed in the chart, the provider will notify Personal Choice's Pre-Admission Certification Service to pre-certify the treatment. However, if you use a Blue Cross/Blue Shield PPO provider under the BlueCard PPO Program or a non-preferred provider, you or a member of your family must notify the Pre-Admission Certification Service at 1-800-332-2566. If you use a Blue Cross/Blue Shield PPO provider or a non-preferred provider and you fail to pre-certify the treatment, you will be subject to a penalty as discussed below in the section titled "Penalty for Failure to Obtain Pre-Certification." The call to pre-certify must be made:   Prior to a planned hospital admission including short procedure unit, skilled nursing facility, home health care, or hospice. Within two business days of an emergency admission.  If you are pregnant, call as soon as your doctor confirms that you are pregnant and again within 24 hours of the birth. When you call Personal Choice’s Pre-Admission Certification Service, be prepared to provide: Your name and social security number; Patient's name;  The treating physician's name, address and phone number; The name of the hospital and the anticipated admission date; Your employer's name and group plan number. You do not need to call in advance of an emergency room visit or before you seek treatment for an emergency. However, if you are going to be admitted after emergency room care, you are required to follow pre-certification notification as described above. Penalty for failure to obtain pre-certification If you fail to follow the procedures for pre-certification when you use a BlueCard PPO provider under the BlueCard PPO Program or non-preferred provider, Personal Choice will reduce its benefit payment by $1,000 for all inpatient hospital admissions and by 20% for all other services that require pre-certification. You will be responsible for paying this penalty amount. If Personal Choice's Pre-Admission Certification Service does not approve your treatment, you, your doctor, or the hospital may appeal this decision.

Services that required pre-certification
Service	Preferred (Personal Choice Network or BlueCard PPO Program)	Non-preferred
All Non-Emergency Inpatient Admissions	Required	Required
Outpatient Surgical Procedures
Bunionectomy	Required	Required
Cataract Surgery	NOT Required	Required
Laparoscopic  Cholecystectomy	Required	Required
Hemorrhoidectomy	Required	Required
Hernia Repair	NOT Required	Required
Arthroscopic Knee Surgery	Required	Required
Diagnostic Arthroscopy	Required	Required
Ligation and Stripping of Varicose Veins	Required	Required
Prostate Surgery	NOT Required	Required
Spinal/Vertebral Surgery	NOT Required	Required
Submucous Resection (nasal surgery)	Required	Required
Tonsillectomy and/or Adenoidectomy	Required	Required
Transplants	Required	Required
Service	Preferred (Personal Choice Network or BlueCard PPO Program)	Non-preferred
Operative and Diagnostic Endoscopies	NOT Required	Required
MRI	NOT Required	Required
CAT Scan	NOT Required	Required
Outpatient therapies: Physical, Speech, Occupational, Cardiac, Pulmonary, Respiratory, Infusion	Required	Required
Restorative Services, including Chiropractic Care and Related Services	Required	Required
Outpatient Private Duty Nursing	Required	Required
Other Facility  Services: Skilled Nursing, Hospice, Home Health, Birth Center	Required	Required
Non-Emergency Ambulance	Required	Required
Rental of Durable Medical Equipment	Required	Required
Purchase of Durable Medical Equipment over $100	Required	Required
Prosthetics	Required	Required

Concurrent review Personal Choice reviews the care you receive while you are still in the hospital. The concurrent review program serves to insure cost efficiency and the delivery of appropriate treatment.