Medical Management Programs
Not Applicable for Secondary Coverage
Medical management requirements described in this section do not apply when coverage under this Plan is secondary to Medicare or another plan providing benefits for you or your dependents.
In general, Anthem Blue Cross's Medical Management Programs do not apply to Medicare-eligible members. As the primary payer, Medicare's management programs will apply, and the ROP will pay secondarily, based on ROP provisions. However, pre-certification is required for both Medicare and non-Medicare members seeking Skilled Nursing Facility benefits.
Medical management programs are designed to work together with you and your provider to ensure you receive appropriate medical care and avoid unexpected out–of-pocket expenses. The Medical Management Programs at Anthem Blue Cross include the Utilization Review Program, Authorization Program and Personal Case Management. The Utilization Review Program applies to inpatient hospital admissions. The Authorization Program applies to certain specialized services or treatments (e.g., organ and tissue transplants, home health care, or admissions to a skilled nursing facility.) The Personal Case Management Program helps you coordinate and manage long-term intensive medical care.
No benefits are payable, however, unless your coverage is in force at the time services are rendered, and payment of benefits is subject to all the terms and requirements of the Plan. If benefits are denied or reduced as a result of these programs, you may apply for consideration under the claims and appeals process. See the Claims and Appeals Process section for the Anthem Blue Cross-Administered Plans.