Alicare Hospitalization Management
Why is Hospitalization Management Program necessary?
Alicare Medical Management is a comprehensive program which will review
proposed inpatient treatment plans to ensure that a hospital stay is appropriate
and medically necessary. At Alicare, they believe it is important that
you and your family continue to be able to obtain hospital care without
compromising the quality of that care. The hospitalization management
program is designed to encourage you to be a responsible consumer of health
care.
You must use this program anytime your doctor
recommends a hospital admission for you or a covered dependent.
What is Hospitalization Management?
Hospitalization Management requires you to have your
proposed hospital stay reviewed by Alicare's professional staff prior to your
hospital admission. Based on information provided by your doctor, Alicare
will determine whether your hospitalization is medically necessary or if the
treatment might be provided in a different setting. At the same time, they
will assign an initial number of approved hospital days and notify you, your
physician and the hospital. Hospitalization Management does not guarantee
coverage for incurred services. Your hospital stay is still subject to all
other plan coverage rules.
What should I do when my doctor recommends admission to
a hospital for either an eligible dependent or myself?
As soon as you are scheduled for admission, you MUST call
Alicare immediately toll free:
1-800-848-9200 between the hours of 8 a.m. and 6 p.m. EST
Monday through Friday
Be sure to have the following information
available:
- participant's name and Social Security Number
- name of the Fund, I.U.O.E. Local 132 Health & Welfare Fund
- Hospital name and phone number where you will be treated
- date(s) you are planning to enter the hospital
- reason for admission to the hospital
If you call after normal business
hours, you will receive a recorded message instructing you to leave your
name and phone number. Your call will be returned on the next
business day.
Remember, it is your obligation to contact
Alicare. Do not rely on your doctor's office or hospital personnel to do
so.
What happens is I need more hospital days than were
initially approved?
When the initially approved hospital days are up,
Alicare will contact your doctor to learn if you will be discharged. In
cases where your physician decides that an extension of your hospitalization is
required, Alicare will approve additional days, subject to review and approval.
What about urgent or emergency hospital admissions
where there is not time to go through the Hospitalization Management process?
When you or an eligible dependent require an URGENT
admission, your doctor, the hospital or family member should telephone Alicare
at 1-800-848-9200 as soon as possible and provide Alicare with information so
that it can assign an initial number of approved hospital days.
When you or an eligible dependent are
hospitalized for an EMERGENCY, the doctor or a responsible family member must
call Alicare within two (2) business days of the admission to notify them of
the hospital admission.
What should I do about a hospital admission for
pregnancy?
You should call Alicare as soon as you know you are
pregnant. An initial number of days will be approved at that time, and you
will be instructed to notify Alicare when admitted for delivery.
What happens if I do not use the Hospitalization
Management Program?
You are required to call Alicare before admission or
within two (2) business days of an emergency admission. Your benefits will
be reduced by $250 if you do not obtain approval for admission or do not comply
with the recommended duration.
What is Case Management and how does it help my family?
Alicare also provides case management, which is a
special service designed to assist patients with serious illnesses or injuries.
Many people who have used this kind of service have found that it provides
valuable assistance and peace of mind during difficult periods of serious
illness.
Serious medical cases include:
- chronic illnesses
- acute catastrophic injuries
- infectious diseases
- terminal illnesses
- neonatal complications
- burns
Should any of these situations arise, a nurse case
manager will contact you and your family to discuss your medical care
needs. Your personal nurse care manager will help you by:
- facilitating all activities and communications among the
professionals involved in your treatment plan,
- providing information about your treatment options and
- identifying any needed additional medical resources that
may be available to you.
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