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:
    • Air Ambulance (excludes 911 initiated emergency transport)
    • Bone-Anchored and Bone Conduction Hearing Aids
    • Cochlear Implants and Auditory Brainstem Implants
    • Corneal Collagen Cross-Linking
    • Cryopreservation of Oocytes or Ovarian Tissue
    • Diaphragmatic/Phrenic Nerve Stimulation pacing systems
    • Deep Brain, Cortical, and Cerebellar Stimulation
    • Electric Tumor Treatment Field (TTF) for treatment of glioblastoma
    • Immunoprophylaxis for respiratory syncytial virus (RSV)
    • Implantable Middle Ear Hearing Aids
    • Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
    • Keratoprosthesis
    • MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
    • Occipital nerve stimulation
    • Percutaneous Neurolysis for Chronic Neck and Back Pain
    • Photocoagulation of Macular Drusen
    • Private Duty Nursing
    • Presbyopia and Stigmatism – Correcting Intraocular Lenses
    • Radiofrequency Ablation to Treat Tumors Outside the Liver
    • Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia
    • Treatment of Hyperhidrosis
    • Treatments for Urinary Incontinence
    • Transcatheter Uterine Artery Embolization
    • Treatment of Temporomandibular Disorders
    • Vagus Nerve Stimulation
  • Diagnostic Testing:
    • Cardiac Ion Channel Genetic Testing
    • Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies
    • Gene Expression Profiling for Managing Breast Cancer Treatment
    • Genetic Testing for Breast and/or Ovarian Cancer Syndrome
    • Genetic Testing for Cancer Susceptibility
    • Preimplantation Genetic Diagnosis Testing
    • SmartPillTM Motility Testing
    • Prostate Saturation Biopsy
  • Durable Medical Equipment (DME)/Prosthetics:
    • Augmentative and Alternative Communication (AAC) Devices/ Speech Generating Devices (SGD)
    • Continuous Interstitial Glucose Monitoring
    • Custom-made Knee Braces
    • Dynamic Low-Load Prolonged-Duration Stretch Devices (LLPS)
    • Electrical Bone Growth Stimulation
    • External (Portable) Continuous Insulin Infusion Pump
    • Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)
    • Implantable Infusion Pumps
    • Lower Limb Prosthesis and Microprocessor Controlled Lower Limb Prosthesis
    • Oscillatory Devices for Airway Clearance including High Frequency Chest Compression and Intrapulmonary Percussive Ventilation (IPV)
    • Pneumatic Compression Devices for Lymphedema
    • Ultrasound Bone Growth Stimulation
    • Wheeled Mobility Devices: Wheelchairs-Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs)
    • Prosthetics: Electronic or externally powered and select other prosthetics- (myoelectric-UE)
    • Standing Frame
    • Transtympanic Micropressure for the Treatment of Ménière's Disease
  • Radiation Therapy/Radiology Services:
    • Intensity Modulated Radiation Therapy (IMRT)
    • Magnetic Source Imaging and Magnetoencephalography (MSI/MEG)
    • Single Photon Emission Computed Tomography (SPECT) Scans for Noncardiovascular Indications
    • Proton Beam Therapy
    • Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiotherapy (SBRT)
    • Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for treating Primary or Metastatic Liver Tumors
    • Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Malignant Lesions Outside the Liver- except CNS and Spinal Cord
    • Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule
  • Surgical Services:
    • Ablative Techniques as a Treatment for Barrett's Esophagus
    • Balloon and Self-Expanding Absorptive Sinus Ostial Dilation
    • Bariatric Surgery and Other Treatments for Clinically Severe Obesity
    • Bronchial Thermoplasty for Treatment of Asthma
    • Cardio-Vascular
      • Cardiac Resynchronization Therapy (CRT) with or without an Implantable Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure
      • Carotid, Vertebral and Intracranial Artery Angioplasty with or without Stent Placement
      • Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities
      • Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry
      • Implantable or Wearable Cardioverter-Defibrillator
      • Maze Procedure
      • Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)
      • Mechanical Embolectomy for Treatment of Acute Stroke
      • Partial Left Ventriculectomy
      • Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention
      • Transcatheter Heart Valve Procedures
      • Transmyocardial/Perventricular Device Closure of Ventricular Septal Defects
      • Treatment of Varicose Veins (Lower Extremities)
      • Venous Angioplasty with or without Stent Placement/ Venous Stenting
    • Cryosurgical Ablation of Solid Tumors Outside the Liver
    • Functional Endoscopic Sinus Surgery
    • Gastric Electrical Stimulation
    • Lung Volume Reduction Surgery
    • Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies
    • Musculo-Skeletal Surgeries:
      • Axial Lumbar Interbody Fusion
      • Cervical Total Disc Arthoplasty
      • Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System
      • Extracorporeal Shock Wave Therapy for Orthopedic Conditions
      • Implanted Devices for Spinal Stenosis
      • Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS)
      • Lumbar Discography
      • Lumbar Laminectomy, Hemi-Laminectomy, Laminotomy and/or Discectomy
      • Lumbar Spinal Fusion and Lumbar Total Disc Arthroplasty
      • Lysis of Epidural Adhesions
      • Manipulation Under Anesthesia of the Spine and Joints other than the Knee
      • Meniscal Allograft Transplantation of the Knee
      • Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty
      • Sacroiliac Joint Fusion
      • Surgical Interventions for Scoliosis and Spinal Deformity
      • Total Ankle Replacement
      • Treatment of Osteochondral Defects of the Knee and Ankle
    • Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome
    • Plastic/Reconstructive surgeries/treatments:
      • Abdominoplasty, Panniculectomy, Diastasis Recti Repair
      • Blepharoplasty
      • Brachioplasty
      • Breast Procedures; including Reconstructive Surgery, Implants and other Breast Procedures
      • Buttock/Thigh Lift
      • Chin Implant, Mentoplasty, Osteoplasty Mandible
      • Composite Products for Wound Healing and Soft Tissue Grafting
      • Insertion/Injection of Prosthetic Material Collagen Implants
      • Hyperbaric Oxygen Therapy (Systemic/Topical)
      • Liposuction/Lipectomy
      • Mandibular/Maxillary (Orthognathic) Surgery
      • Mastectomy for Gynecomastia
      • Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
      • Penile Prosthesis Implantation
      • Procedures Performed on the Face, Jaw or Neck (including facial dermabrasion, scar revision)
      • Procedures Performed on Male or Female Genitalia
      • Procedures Performed on the Trunk and Groin
      • Reduction Mammaplasty
      • Repair of Pectus Excavatum / Carinatum
      • Rhinoplasty
      • Septoplasty
      • Skin-Related Procedures
    • Sacral Nerve Stimulation (SNS) and Percutaneous Tibial Nerve Stimulation (PTNS) for Urinary and Fecal Incontinence and Urinary Retention
    • Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
    • Surgical and Ablative Treatments for Chronic Headaches
    • Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other GU Conditions
    • Transanal Hemorrhoidal Dearterialization (THD)
    • Surgical Treatment of Obstructive Sleep Apnea and Snoring
    • Viscocanalostomy and Canaloplasty
  • Gender Reassignment Surgery
  • Human Organ and Bone Marrow/Stem Cell Transplants
    • Inpatient admits for ALL solid organ and bone marrow/stem cell transplants (including Kidney only transplants)
    • Outpatient: All procedures considered to be transplant or transplant related including but not limited to:
      • Stem Cell/Bone Marrow transplant (with or without myeloablative therapy)
      • Donor Leukocyte Infusion
    • (CAR) T-cell immunotherapy treatment
    • Gene replacement therapy intended to treat retinal dystrophies
    • Intrathecal treatment of Spinal Muscular Atrophy (SMA)
  • 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 Behavorial 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. Case management review may even recommend services and equipment 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).