Hospital Pre-Admission Certification

Before being confined in a hospital for any non-emergency treatment or services, you or your doctor must contact the Pre-Admission Certification service.  Their toll free number is shown on your H&W Identification card and the back cover of this booklet.  If you contact them personally, please have your attending physician’s name and telephone number available so the service can contact your attending physician’s office.  If your physician contacts the Pre-Admission Certification service you need to do nothing as they will gather all medically necessary information from your doctor.

The Pre-Admission Certification service will determine the appropriateness of your hospitalization.  After making this determination, they will send a letter of authorization with all the appropriate information to your attending physician, the hospital you plan to use, the Plan Administrator and yourself.  This letter will indicate if the hospitalization was necessary.  After you enter the hospital, the Pre-Admission Certification service will be in contact with the hospital and your attending physician to follow your progress.

Hospital Pre-Admission Certification Penalty

If you do not follow the Pre-Admission Certification process for a non-emergency admission, the Plan will deduct an additional $250 from the hospital miscellaneous charges.  You will be required to pay the excess, which will not count toward the maximum annual out-of-pocket limit.

If you or your dependents enter the hospital before the approved date or remain in the hospital beyond the period for which approval was granted and such extended stay is not deemed to be medically necessary, as defined by the Plan, the $250 penalty will apply.

If you are admitted to a hospital due to an emergency, the Pre-Admission Certification service must be notified within two (2) business days of your admission.  If you fail to comply with this provision, the $250 penalty will apply.