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 Admission:
    • Inclusive of all Acute Inpatient, Skilled Nursing Facility, Long Term Acute Rehab, and OB delivery stays beyond the Federal Mandate minimum LOS (including newborn stays beyond the mother's stay)
    • Emergency Admissions (Requires Plan notification no later than 2 business days after admission
  • Outpatient and Surgical Services:
    • Abdominoplasty, panniculectomy, diastasis recti repair
    • Ablative techniques as a treatment for Barrett's Esophagus
    • Air Ambulance (excludes 911 initiated emergency transport)
    • Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
    • Artificial intervertebral disc
    • Autologous Cellular Immunotherapy for the Treatment of Prostate Cancer/Sipuleucel-T (Provenge®)
    • Balloon sinuplasty
    • Bariatric surgery
    • Blepharoplasty
    • Bone-Anchored and Bone Conduction Hearing Aids
    • Bone growth stimulator: Electric or Ultrasound
    • Brachioplasty
    • Breast procedures: including reconstructive surgery, implants, reduction, mastectomy for gynecomastia and other breast procedures
    • Bronchial Thermoplasty for Treatment of Asthma
    • Buttock/Thigh Lift
    • Cardiac Ion Channel Genetic Testing
    • Cardiac resynchronization therapy (CRT) with or without Implantable Cardioverter
    • Carotid, Vertebral and intracranial artery angioplasty with or without stent placement
    • Cervical total disc arthroplasty
    • Chin Implant, mentoplasty, osteoplasty, mandible
    • Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies
    • Cochlear Implants and Auditory Brainstem Implants
    • Communication assisting/Speech generating devices
    • Computer-assisted musculoskeletal surgical navigational orthopedic procedures of the appendicular system
    • Constant intestinal glucose monitoring
    • Cryosurgical ablation of solid tumors outside the liver
    • Cryopreservation of Oocytes or Ovarian Tissue
    • Cryosurgical Ablation of Solid Tumors Outside the Liver
    • Custom –made Knee Braces
    • Deep Brain, Cortical, and Cerebellar Stimulation
    • Defibrillator (CER/ICD) for the treatment of heart failure
    • Dynamic Low-Low Proonged Duration Stretch Devices (LLPS)
    • Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities
    • External (portable) continuous insulin infusion pump
    • Extracorporeal shock wave therapy for orthopedic conditions
    • Functional electronical stimulation (FES); Threshold electrical stimulation (TES)
    • Functional endoscopic sinus surgery
    • Gastric electrical stimulation
    • Gender reassignment surgery
    • Gene Expression Profiling for Managing Breast Cancer Treatment
    • Genetic Testing for Breast and/or Ovarian Cancer Syndrome
    • Genetic Testing for Colorectal Cancer Susceptibility
    • Gene Therapy including gene replacement therapy
    • Gene Replace Therapy for retinal dystrophies
    • Hyperbaric oxygen therapy (Systemic/Topical)
    • Implantable ambulatory event monitors and mobile cardiac telemetry
    • Implantable devices for spinal stenosis
    • Implantable infusion pumps
    • Implantable Middle Ear Hearing Aids
    • Implantable or wearable cardioverter-defibrillator
    • Implanted spinal cord stimulators
    • Insertion/injection of prosthetic material collagen implants
    • Intensity modulated radiation therapy (IMRT)Intensive Outpatient Therapy (IOP) for Behavioral Health
    • Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
    • Intrathecal treatment of Spinal Muscular Atrophy (SMA)
    • Keratoprosthesis
    • Liposuction/lipectomy
    • Locally ablative techniques for treating primary and metastatic liver malignancies
    • Lower Esophageal Sphincter Augmentation Devices for the Treatment of Gastroesophageal Reflux Disease (GERD)
    • Lumbar Discography
    • Lumbar spine surgeries
    • Lung volume reduction surgery
    • Lysis of epidural adhesions
    • Magnetic Source Imaging and Magnetoencephalography (MSI/MEG)
    • Manipulation under anesthesia of the spine and joints other than the knee
    • Maze procedure
    • Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)
    • Mechanical Embolectomy for Treatment of Acute Stroke
    • Meniscal Allograft Transplantation of the Knee
    • Microprocessor controlled lower limb prosthesis
    • MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
    • Occipital nerve stimulation
    • Oral, pharyngeal and maxillofacial surgical treatment for obstructive sleep apnea
    • Orthognathic surgery
    • Oscillatory devices for airway clearance including high frequency chest compression and intrapulmonary percussive ventiliation (IPV)
    • Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management
    • Ovarian and internal iliac vein embolization as a treatment of pelvic congestion syndrome
    • Partial Hospitalization for Behavioral Health
    • Partial left ventriculectomy
    • Penile prosthesis implantation
    • Percutaneous Neurolysis for Chronic Neck and Back Pain
    • Percutaneous spinal procedures
    • Percutaneous Vertebroplasty, kyphoplasty, and sacroplasty
    • Perirectal Spacers for Use During Prostate Radiotherapy
    • Pneumatic compression devises for lymphedma
    • Power wheeled mobility devices
    • Presbyopia and Stigmatism – Correcting Intraocular Lenses
    • Preimplantation Genetic Diagnosis Testing
    • Private Duty Nursing
    • Procedures performed on male or female genitalia
    • Procedures performed on the face, jaw or neck (including facial dermabrasion, scar revision)
    • Procedure performed on the trunk and groin
    • Prostate Saturation Biopsy
    • Prosthetics: electronic or externally powered and select other prosthetics
    • Proton beam therapy
    • Radiofrequency Ablation to Treat Tumors Outside the Liver
    • Repair of pectus excavatum/carinatum
    • Residential Care (RTC)
    • Rhinoplasty
    • Sacral nerve stimulation as a treatment of neurogenic bladder secondary to spinal cord injury
    • Sacral Nerve Stimulation (SNS) and Percutaneous Tibial Nerve Stimulation (PTNS) for Urinary and Fecal Incontinence; Urinary Retention
    • Sacroiliac joint fusion
    • Septoplasty
    • Single Proton Emission Computed Tomography (SPECT) Scans for Noncardiovascular Indications
    • Skin-related procedures
    • SmartPill™ Motility Testing
    • Standing frame
    • Stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT)
    • Surgical and ablative treatment for chronic headache
    • Surgical and minimally invasive treatments for benign prostatic hyperplasia (BPH) and other GU conditions
    • Total ankle replacement
    • Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation (Radiofrequency and Cryoablation)
    • Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Emolization (TAE) for treating Priamary or Metastatic Liver Tumors
    • Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Malignant Lesions Outside the Liver – except CNS and Spinal Cord
    • Transcatheter closure of patent foramen ovale and left atrial appendage for stroke prevention
    • Transcatheter Heart Valve Procedures
    • Transcatheter Uterine Artery EmbolizationTranscranial Magnetic Stimulation (TMS)
    • Transplant – all procedures
    • Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia
    • Transmyocardial/Perventricular Device Closure of Ventricular Septal Defects
    • Transtympanic micropressure for the treatment of Meniere's disease
    • Treatment of Hyperhidrosis
    • Treatment of obstructive sleep apnea, UPPP
    • Treatment of osteochondral defects
    • Treatment of Temporomandibular Disorders
    • Vagus Nerve Stimulation
    • Varicose vein treatment
    • Viscocanalostomy and canaloplasty
    • Wheeled Mobility Devices: Manual Wheelchairs – Ultra Lighweight
    • WirelessCasule Endoscopy for Gastrointestinal Imaging and the Patency Capsule
  • Out-of-Network Referrals:
  • Out-of-Network Services for consideration of payment at Network benefit level (may be authorized, based on Network availability and/or medical necessity.)
  • Mental Health/Substance Abuse (MHSA):
    • Pre-Certification Required
      • Acute Inpatient Admissions
      • Applied Behavioral Analysis
      • Transcranial Magnetic Stimulation (TMS)
      • Intensive Outpatient Therapy (IOP)
      • Partial Hospitalization (PHP)
      • Residential Care
      • Behavioral Health in-home Programs
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 15 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 15 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, there will be no penalty.
You are responsible for preauthorizing out-of-network services only. Your in-network provider will preauthorize all other services related to inpatient admissions, but you are responsible for authorizing all other required services.
What approvals do I need if I am going into the hospital?
You must obtain preauthorization as soon as possible but at least 15 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. 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).