MMC Benefits Handbook
Utilization Review
Which utilization review services are offered?
The Plan offers preauthorization and case management review.
You may obtain more information about these review services by calling the Claims Administrator.
What is Preauthorization?
Preauthorization is a utilization review service performed by licensed healthcare professionals. The intent is to determine medical necessity and appropriateness of proposed treatment, including level of care, benefit coverage and eligibility.
In many cases, your Non-Network Benefits will be reduced if the Claims Administrator has not provided preauthorization.
What services require preauthorization?
The following types of medical expenses require preauthorization:
  • Air Ambulance (air ambulance only suspends for medical review, there is no penalty applied)
  • Hip Procedures (Inpatient and Outpatient)
  • Home Health Care
  • Home Infusion Therapy (billed by home infusion specialist)
  • Infertility Services
  • Inpatient Hospital
  • Interventional Pain Management (Outpatient)
  • Knee Procedures (Inpatient and Outpatient)
  • Obesity Surgery
  • Private Duty Nursing Care
  • Rehabilitation Facility
  • Residential Treatment for treatment of mental health and substance abuse
  • Skilled Nursing Facility
You must also receive preauthorization for:
  • All hospital admissions including
    • Alcohol and Substance Abuse
    • All inpatient surgeries
    • Mental Health
    • Organ Transplant
  • Gender Reassignment Surgery
  • Visiting Nurses
Additional Behavioral Health Services
1. Transcranial Magnetic Stimulation (TSM)
2. Partial Hospitalization
3. Psychological & Neurological Testing
If you have an emergency hospital admission, surgery or specified procedure, you, a family member, your physician or the hospital must preauthorize within 48 hours of service.
If the procedure or treatment is performed for any condition other than an emergency condition, the call must be made at least 14 days before the date the procedure is to be performed or the treatment is to start. If it is not possible to make the call during the specified time, it must be made as soon as reasonably possible before the date the procedure or treatment is to be performed.
If you are receiving an infused medication, certain medications may require use of the lowest cost site of care.
Do I need to have my maternity coverage preauthorized?
No. Preauthorization within 48 hours is not required for the initial hospital admission.
You must notify the preauthorization service if the mother or her newborn stay in the hospital longer than 48 hours after a vaginal delivery or 96 hours after a Cesarean birth. This notification must occur within 24 hours of the determination to extend the stay.
When do I obtain preauthorization?
You, your family member or health care professional must obtain preauthorization as soon as you know you need a service requiring preauthorization, but not less than 14 days prior to the procedure or treatment.
Note: You are responsible for ensuring your service has been preauthorized.
How do I obtain preauthorization?
Initiate the preauthorization process by calling the Claims Administrator.
What happens if I fail to obtain preauthorization?
If you fail to obtain preauthorization, your out-of-network benefits will be reduced by $400 of covered expenses for inpatient hospital, treatment facility, skilled nursing facility, home health care, private duty nursing and hospice. (Preauthorization penalties do not apply towards your deductible or out-of-pocket maximum.)
You are responsible for preauthorizing out-of-network services only. Your in-network provider will preauthorize all other services.
What approvals do I need if I am going into the hospital?
You must obtain preauthorization as soon as possible but at least 14 days before you are admitted for a non-emergency hospital admission or stay.
If you have an emergency hospital admission, surgery or specified procedure, you, a family member, your physician or the hospital must preauthorize within 48 hours of the service.
Case Management Review
When the preauthorization service identifies a major medical condition, that condition will be subject to case management review. Case management review aims at identifying major medical conditions early in the treatment plan and makes recommendations regarding the medical necessity of requested health care services.
Case managers with experience in intensive medical treatment and rehabilitation provide case management services. The case manager works with the patient's physician to identify available resources and develop the best treatment plan. Case management review may even recommend services and equipment that the Plan would not ordinarily cover.
In addition, the case manager can coordinate the various caregivers, such as occupational or physical therapists, required by the patient. Situations that may benefit from case management include severe illnesses and injuries such as:
  • Head trauma
  • Organ transplants
  • Burn cases
  • Neo-natal high risk infants
  • Multiple fractures
  • HIV-related conditions
  • Brain injuries
  • Cancer
  • Prolonged illnesses
  • Degenerative neurological disorders (e.g. multiple sclerosis).
To best help the patient, the case managers should be involved from the earliest stages of a major condition. This service gives you access to a knowledgeable case manager who will use his or her expertise to assist you and your physician in considering your treatment options.
If the case managers questions the necessity of the proposed hospital admission or procedure, a physician advisor may contact your physician to discuss your case and suggest other treatment options that are generally utilized for your condition. Your physician may also be asked to adhere to Aetna's evidence-based treatment protocols when treating oncology patients. You, your physician, and the case manager will be informed of the outcome of the review, and the Claims Administrator will determine the level of benefit coverage you will receive. You and your physician will be notified of the utilization reviewer's recommendation by telephone and in writing. You will also be informed of the appeal process if the procedures your physician ultimately recommends are not covered under the Plan (as determined by the Claims Administrator).