MMC Benefits Handbook
Utilization Review
Which utilization review services are offered?
The Plan offers prior authorization and case management review.
You may obtain more information about these review services by calling the Claims Administrator.
What is Prior Authorization?
Select services require prior authorization or pre-admission notification. Prior authorization is required by service type, regardless of whether the service is rendered by in-network or out-of-network Providers.
In-network Providers are responsible for obtaining prior authorization for select Covered Health Services and are responsible for pre-admission notification for planned inpatient admissions and post-admission notification at least 24 hours of admission of Emergency inpatient admissions. Inpatient stays will be reviewed for Medical Necessity, length of stay, and level of care. All acute inpatient rehabilitation (AIR) admissions, long-term acute care (LTAC) admissions, and Skilled Nursing Facility (SNF) admissions are subject to Medical Necessity review pre-admission.
If you have questions about prior authorization or pre-admission notification, please contact Surest Member Services.
If you are using an out-of-network provider, you are responsible for ensuring that any necessary prior Authorizations and pre-admission notifications have been obtained or the services may not be covered by the Surest Plan. Only certain out-of-network Covered Health Services are available for benefits (e.g., ambulance, emergency room, observation stay). Contact Surest Member Services prior to obtaining services to determine whether prior authorization is required or ask your provider to contact the pre-certification number on your member ID card.
If your prior authorization or pre-admission notification is denied, you will receive an explanation of why it was denied and how you can appeal (including how to request expedited review).
The prior authorization list is subject to change without notice. The most current information can be obtained by having your provider contact the pre-certification number on your member ID card or call Surest Member Services.
What services require prior authorization?
The following types of medical expenses require prior authorization or benefit determination, according to the Claims Administrator's medical policies:
- Acute care hospitalizations (planned)
- Acute inpatient rehabilitation
- Applied behavioral analysis
- Air transportation for non-emergency
- Bariatric surgery
- Bone growth stimulators
- BRCA testing
- Cardiovascular procedures (select)
- Chemotherapy (select)
- Clinical trials
- Cochlear implant surgery
- Coverage with Evidence Development
- Durable medical equipment, orthotics, and prosthetics (select)
- Gender affirming surgery
- Genetic and molecular tests (select)
- Injectable medications (select)
- Intensity-modulated radiation therapy
- Long-term acute care
- MR-guided focused ultrasound
- Organ transplants
- Orthognathic surgery
- Partial hospitalization
- Potentially Cosmetic and Reconstructive surgery
- Proton beam therapy
- Residential treatment facilities
- Skilled Nursing Facilities
- Sleep apnea procedures
- Sleep studies
- Spinal surgeries (select)
- Vein procedures
- Ventricular assist devices
Do I need to obtain prior authorization for my maternity coverage?
No. Prior authorization within 48 hours is not required for the initial hospital admission.
You must notify the prior authorization 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 prior authorization?
In-network providers are responsible for obtaining Prior Authorization for select Covered Health Services and are responsible for Pre-Admission Notification for planned inpatient admissions and post-admission notification within at least 24 hours of an Emergency inpatient admission.
Note: If you are using an out-of-network provider, you are responsible for ensuring prior authorization for your service.
How do I obtain prior authorization?
Initiate the prior authorization process by calling the Claims Administrator at the toll-free number on the back of your ID card.
What happens if I fail to obtain prior authorization?
If you are using an out-of-network provider, you are responsible for ensuring that any necessary prior authorizations and pre-admission notifications have been obtained, or the services will not be covered by the Plan and you will be responsible for all costs billed by the provider.
What approvals do I need if I am going into the hospital?
All inpatient services require pre-admission Notification if planned, and notification within 24 hours of admission if an emergency.
Clinical Support
The Surest Copay Plan has licensed clinical advocates and nurse case managers to help manage members' complex health care needs. Surest clinical advocates help to assist members with finding providers, providing treatment decision support, and overall care navigation. Surest nurse case managers work with members to understand their needs, set personal goals for care, and ensure needed support is provided. Nurses may guide members through treatment, explain options, advocate for members with their care team, and answer questions about members' care. Members can call Surest Member Services at +1 866 683 6440 for more information on clinical support.
Nurse case managers work with the patient's physician to identify available resources and develop a treatment plan and may even recommend services and equipment. 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).
The nurse can be involved from the earliest stages of a major condition to help the patient. This service gives you access to a knowledgeable professional who will use his or her experience to assist you and your physician in considering your treatment options.