Each HealthChoice Network Provider is contractually obligated to cooperate fully
with all utilization review procedures established by OSEEGIB. Certification
does not verify eligibility or guarantee benefits but determines medical
necessity.
A 10% penalty will be assessed to the provider's payment if certification is not
obtained or certification is not initiated within the established time
guidelines. The 10% penalty is not the financial responsibility of the
patient/member.
Certification can be obtained by calling
APS Healthcare
The provider must have the following information available at the time of the
certification request:
The VoiCert automated phone system is available to request certifications. Call
APS and follow the telephone prompts to leave information through VoiCert.
Certification is required for the following services and performed by the Health
Care Management Division at OSEEGIB:
Certification by APS Healthcare is required for the following procedures:
- Blepharoplasty
- Breast Implant removal
- Breast Reduction
- Panniculectomy
- Rhinoplasty
- Scar revision
- Surgical Treatment of Varicose Veins
The Network Provider and the member equally share the responsibility to obtain
certification for hospital admissions. OSEEGIB requires all non-emergency
hospital admissions be certified at least three working days prior to the
actual admission (this excludes maternity admissions for the delivery of a
newborn, which do not require certification). Emergency admissions require
notification within 24 hours (one working day) of the actual admission date.
Holiday or weekend admissions must be certified by the first working day
following the date of hospital confinement. The hospital, physician and the
member will receive a letter verifying certification.
Upon initiation of the certification process, a reference number will be
assigned to the particular case (assignment of a reference number does not
complete the certification process or guarantee benefits). Utilization Review
staff members will review medical information pertaining to the patient. If the
initial requirements are met, the 10% penalty will not be assessed.
APS will update the progress of the patient at established intervals during the
concurrent review process. The medical necessity of additional inpatient days is
also determined during the concurrent review process. APS performs retrospective
reviews/appeals. A retrospective review/appeal could be warranted in the
following situations:
Confinements billed as “observation”, in which room and board charges are
incurred, will be paid based on inpatient benefits if the stay is certified.
Confinements billed as “observation” with a duration of more than 24 hours must
be certified within one working day.
Claims submitted for certified inpatient hospital admissions with a duration of
less than 24 hours will be processed utilizing benefits for outpatient hospital
services (unless room and board charges are incurred).
Certification by APS Healthcare is required for the following procedures:
* Blepharoplasty
* Breast Implant removal
* Breast Reduction
* Panniculectomy
* Rhinoplasty
* Scar revision
* Surgical Treatment of Varicose Veins
