Benefits Handbook

The Plan offers preauthorization and case management review.

You may obtain more information about these review services by calling the Claims Administrator.

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.

The following types of medical expenses require preauthorization:

Out of Network Services for consideration of payment at in-network benefit level (may be authorized, based on network availability and/or medical necessity.)

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.

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.

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.

Initiate the preauthorization process by calling the Claims Administrator.

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.

Note: To receive coverage for infertility-related treatments and services, you MUST use a provider in WIN's provider network and obtain required preauthorization.

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.

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:

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).