How Do You Receive Advance Approval for Hospitalization,
Surgical and Diagnostic Procedures, and Alternate Care
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What Is the Toll-Free Number for Advance
Approval
How Do You Receive Advance Approval for
Hospital Admissions
How Do You Receive Advance Approval for
Surgical and Diagnostic Procedures
How Do You Receive Advance Approval for
Alternate Care
Managed Choice POS requires you to receive advance approval
for certain types of out-of-network or out-of-area services.
Advance approval is required for hospital admissions, certain
outpatient surgical and diagnostic procedures, skilled nursing
facilities, home health care, and hospice care.
Obtaining advance approval helps you avoid unnecessary risk
and extra cost by confirming the need for proposed medical
treatment. This service is provided by Blue Cross Blue Shield of Illinois.
What Is the Toll-Free Number for
Advance Approval
To begin the advance approval process,
simply call Blue Cross Blue Shield of Illinois at the number listed on your identification
card. A medical professional will work with you and your doctor
to review your condition and proposed treatment to ensure
appropriate care. Your Managed Choice POS ID card has a summary
of when advance approval is required.
The toll-free number is answered Monday through Friday from
8 a.m. To 6 p.m., Central time. You will receive a reference
number to verify the fact that you have called. If you call
after hours or during a holiday, you can leave a recorded
message. By leaving a message, you have fulfilled your responsibility.
An Blue Cross Blue Shield of Illinois representative will contact you as soon as possible
on the next working day.
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How Do You Receive Advance Approval
for Hospital Admissions
For hospital admissions, you must request advance approval:
- At least seven days before admission for non-emergency
conditions, or as soon as hospitalization has been suggested
if less than seven days before admission.
- Within 48 hours after admission in an emergency.
If you do not call Aetna for advance approval of hospitalization
within these time limits, benefits payable for the hospitalization
will be reduced by $300. The approval will determine the necessity
for the hospitalization and the appropriate length of stay
for the medical condition being treated. Certain measures
that can reduce the length of stay may be required, such as
pre-admission tests. In addition, a medical professional will
monitor your progress to determine if additional days in the
hospital are needed. If your doctor does not agree with the
results of the approval process, your doctor can request a
review.
If the review process results in a continued disagreement
with your doctor, you can still be hospitalized, but you will
receive reduced benefits. For example, if the hospital stay
is not medically necessary, such as hospitalization for a
surgery that should be performed on an outpatient basis, no
room and board benefits will be paid. In that case, other
covered hospital expenses will be paid at 80%, subject to
the deductible, if the expenses are medically necessary. If
the hospital stay is due to treatment not covered by the plan,
such as hospitalization for elective cosmetic surgery, no
benefits will be available for the hospitalization.
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How Do You Receive Advance Approval
for Surgical and Diagnostic Procedures
If your doctor recommends any of the following outpatient,
non-emergency surgical or diagnostic procedures, you should
obtain advance approval from Blue Cross Blue Shield of Illinois:
- Amniocentesis
- Cardiac catheterization and other angiographic procedures
- Carpal tunnel release
- Cataract removal
- CT scans
- Deviated nasal septum
- Echocardiogram
- Endoscopic retrograde cholangiopancreatogram (ERCP)
- Hemorrhoidectomy
- Holter monitor testing
- Inguinal hernia
- Lower GI colonoscopy/sigmoidoscopy
- Magnetic resonance imaging (MRI)
- Myringotomy
- Pediatric umbilical hernia (under age 5)
- Rhinoplasty
- Submucous resection (non-cosmetic)
- Tonsil/adenoidectomy
- Treadmill, with or without radioisotope, and any other
cardiac stress testing
- Tubes/ovaries (non-obstetrical and non-sterilization)
- Upper GI endoscopy
- Varicose vein ligation.
If you do not call Blue Cross Blue Shield of Illinois for advance approval of these procedures,
benefits for the procedure will be reduced by $300, provided
the procedure is medically necessary. If the procedure is
not medically necessary, no benefits will be available.
Aetna may require a second surgical opinion and will make
the arrangements and pay the physician in full. If the second
opinion confirms the need for surgery, you will have the peace
of mind in knowing the procedure is necessary. In some cases,
the physician providing the second opinion may discuss alternatives
with your doctor and assist with any alternative arrangements.
If the second opinion does not confirm the need for surgery,
a third opinion can be arranged at no cost to you.
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How Do You Receive Advance Approval
for Alternate Care
Skilled nursing facilities, home health care, and hospice
care require advance approval for benefits to be payable.
There is no coverage if such care is not approved in advance
by Blue Cross Blue Shield of Illinois.
If you exhaust your alternate care benefits, your case may
be a candidate for case management.
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