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:
  • Inpatient confinements (except hospice)
  • Ambulance
    • Precertification required for transportation by fixed-wing aircraft (plane)
  • Autologous chondrocyte implantation
  • Chiari malformation decompression surgery
  • Cochlear device and/or implantation
  • Coverage at an in-network benefit level for out-of-network provider or facility unless services are emergent.
  • Dental implants
  • Dialysis visits
    • When a participating provider initiates request, and dialysis is to be performed at a nonparticipating facility call +1 866 752 7021. Or fax applicable request forms to +1 888 267 3277.
  • Dorsal column (lumbar) neurostimulators: trial or implantation
  • Electric or motorized wheelchairs and scooters
  • Endoscopic nasal balloon dilation procedures
  • Gender reassignment surgery
  • Hip surgery to repair impingement syndrome
  • Hyperbaric oxygen therapy
  • Infertility services and pre-implantation genetic testing
  • Lower limb prosthetics, such as microprocessor-controlled lower limb prosthetics
  • Nonparticipating freestanding ambulatory surgical facility services, when referred by a participating provider
  • Orthognathic surgery procedures, bone grafts, osteotomies and surgical management of the temporomandibular joint
  • Osseointegrated implant
  • Osteochondral allograft/knee
  • Private duty nursing
  • Proton beam radiotherapy
  • Reconstructive or other procedures that maybe considered cosmetic, such as:
    • Blepharoplasty/canthoplasty
    • Breast reconstruction/breast enlargement
    • Breast reduction/mammoplasty
    • Excision of excessive skin due to weight loss
    • Gastroplasty/gastric bypass
    • Lipectomyor excess fat removal
    • Surgery for varicose veins, except stab phlebectomy
  • Shoulder Arthroplasty
  • Spinal procedures, such as:
    • Artificial intervertebral disc surgery (cervical spine)
    • Cervical laminoplasty – precertification required effective 9/1/2019
    • Cervical, lumbar and thoracic laminectomy and\or laminotomy procedures
    • Laminectomy with rhizotomy
    • Spinal fusion surgery
  • Uvulopalatopharyngoplasty, including laser-assisted procedures
  • Ventricular assist devices
  • Video electroencephalograph (EEG)
  • Whole exome sequencing
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.
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).