What if the member needs inpatient hospital care?
If the member needs to be hospitalized, the independently contracted Primary Care Physician will arrange for admission to an independently contracted network hospital. The independently contracted Primary Care Physician will also continue to be responsible for overseeing the administration of care. The hospitalization in most instances must be referred by the independently contracted Primary Care Physician and authorized by UniCare HMO (when applicable) in order for the member to receive benefits for eligible services. This is only a brief summary of the plan. Please refer to the certificate of coverage for more complete details about the plan including benefits, conditions, limitations and exclusions.
UNICARE must certify all inpatient hospital admissions (those requiring an overnight stay in the hospital). • For elective admissions, the member, the member’s physician or a representative must obtain UNICARE’s certification before expenses are incurred. The person making the call should be prepared to give the UNICARE ID number of the covered employee, the name of the patient (if different), the hospital or other provider location, and the full name, address and phone number of the attending physician. • For emergency admissions, the member or a representative should notify UNICARE within 48 hours of the admission. • UNICARE urges women to notify us in the first trimester of a pregnancy. In any case, hospitalization for maternity, like any planned inpatient admission, requires pre-certification two weeks in advance for a scheduled or full-term delivery. Emergency admissions for premature deliveries require notification within 48 hours. If the member does not pre-certify those service
If the member needs to be hospitalized, the Primary Care Physician will arrange for admission to a network hospital. The Primary Care Physician will also continue to be responsible for overseeing care. The hospitalization in most instances must be referred by the Primary Care Physician and authorized by UniCare HMO (when applicable) in order for the member to receive benefits for eligible services. This is only a brief summary of the plan. Please refer to the Certificate of Coverage for complete details about the plan including benefits, limitations and exclusions.
A26. All inpatient admissions (except urgent/emergent admissions) are precertified by telephone for medical necessity and length of stay according to the guidelines in the member’s Evidence of Coverage or Certificate. Emergency admissions are reviewed by telephone for medical necessity within twenty-four hours or the next working day after admission. If medical necessity criteria are met, the admission is then certified for level of care and length of stay. If medical necessity criteria are not met, the case is referred to a physician advisor for determination. The prospective review process evaluates medical necessity, appropriate level of care and assigns expected length of stay. It also identifies catastrophic diagnoses for potential case management referral and redirects or channels care to appropriate network providers when indicated. PPO providers are contractually bound to initiate utilization reviews for the member, or the member can call a toll-free number to initiate the proc
