Pre-certification using Medi-Call

What is Medi-Call?

Medi-Call is used to pre-certify various treatments or procedures to make sure you

receive the appropriate medical care in the most beneficial and cost-effective manner.

 

What services must be pre-certified?

You must call Medi-Call if you or a covered member of your family require the

following services:

 

v     You need inpatient care in a hospital;

v     You need outpatient surgery for septoplasty (nasal surgery), hysterectomy, or sclerotherapy (surgery for spider veins);

v     You need an MRA, MRI or CT (Cat) Scan;

v     You will be receiving chemotherapy or radiation therapy;

v     Your outpatient services result in you being admitted to the hospital (even if you pre-certified the outpatient service, you must call again);

v     You need a second opinion;

v     You are admitted to a hospital in an emergency situation (your admission should be reported within 48 hours or the next working day);

v     You become pregnant (you must call within the first three months of your pregnancy);

v     You have an emergency admission during pregnancy;

v     You deliver your baby;

v     Your newborn has complications at birth;

v     You are admitted to a nursing facility, use home health care, hospice care, an alternative treatment program, or need durable medical equipment;

v     You undergo any In Vitro Fertilization procedure;

v     You need to be evaluated for a transplant;

v     You need inpatient rehabilitation and related outpatient physical, speech, and occupational therapies;

v     Any procedure that may potentially be considered cosmetic in nature must be received in writing by Medi-Call seven days prior to surgery;

v     For mental health or substance abuse you must call APS Healthcare at 1-800-221-8699 to pre-certify prior to admission, or within 24 hour of an emergency admission;

 

Are there penalties for not calling?

YES!! If you do not call, you will pay a $200 penalty for each hospital or nursing

admission. In addition, the $2,000/$4,000 coinsurance maximum will not apply. If you

do not call APS Healthcare for mental health or substance abuse, service will not be

covered at all.

 

Important Note Regarding Your Responsibilities:

Always remember it is your responsibility to call. If your physician states they will call,

that does not relieve you of the responsibility. Get the confirmation # or the name of the

person you talk to and the date and time you called even if they tell you that everything is

fine, get their name. Keep this for your records.

 

Calling Medi-Call to Initiate a Certification:

v     Call 1-800-925-9724

v     When you hear the menu Press 2 you are a member

v     Press 3 to Initiate a Pre-certification

v     Key in the SSN of the employee

v     Key in the DOB of the patient

v     Key in the Date of service (this is the day of the appointment/surgery/admission

 

At this point you will either receive a confirmation number or they will ask for a phone

number where you can be reached. If they give you a number, write it down.

 

After that, it will ask you if you want to speak with a representative, you DO. Write

down whom you talked to and the time and date you called. Keep this information for your

records.

 

IF YOU ARE IN DOUBT ABOUT WHETHER YOU NEED TO PRE-CERTIFY, CALL MEDI-CALL JUST TO BE SURE.