What services require prior approval or a referral?
• Women may go to a network OB/GYN doctor for pregnancy, gynecological problems or annual exams without a PCP referral. • Required for ALL hospital admissions. Emergency or maternity admissions must be certified within 48 hours. • Required for specified procedures as listed in the Pre-Admission Certification (PAC) of your Contract. FlexPlus Members • Required for ALL hospital admissions. Emergency care admissions must be certified within 48 hours. If you are hospitalized and pre-admission certification was not obtained, all charges will be denied. Hospital/Surgical Members • Required for ALL hospital admissions. Emergency care admissions must be certified within 48 hours. If you are hospitalized and pre-admission certification was not obtained, all charges will be denied.
