PRE-TREATMENT REVIEW

This plan is administered by Allegiance Benefit Plan Management. All claims are submitted to Allegiance for pricing and payment under the appropriate plan and benefit.

Pre-treatment Review: This is a review for the medical necessity of the treatment or service requested prior to the service being rendered

To initiate this process, a physician office may submit the following to the Plan Supervisor at P.O. Box 3018, Missoula, MT 59806-3018:

1. A complete description of the procedure(s) or treatment(s) for which review is requested;
2. A complete diagnosis and all medical records regarding the condition that supports the requested procedure(s) or treatment(s), including, but not limited to, informed consent form(s), all lab and/or x-rays, or diagnostic studies;
3. An itemized statement of the cost of such procedure(s) or treatment(s) with corresponding CPT or HCPCS codes
4. The attending Physician’s prescription, if applicable;
5. A Physician’s referral letter, if applicable;
6. A letter of medical necessity;
7. A written treatment plan; and
8. Any other information deemed necessary to evaluate the request for Pre-treatment Review. Upon receipt of all required information, the Plan will provide a written response to the written request for pre-treatment review of services.

THE BENEFITS QUOTED ARE NOT A GUARANTEE OF PAYMENT. FINAL DETERMINATION AS TO BENEFITS PAID WILL BE MADE AT THE TIME THE CLAIM IS SUBMITTED FOR PAYMENT WITH REVIEW OF NECESSARY MEDICAL RECORDS AND OTHER INFORMATION.

You may call Customer Service for help with this process by dialing 855-999-1522. You may also fax your request to 406-532-3513. Determinations are made for standard reviews within 3-5 business days. Urgent requests can be expedited.

PRE-CERTIFICATION REVIEW

Pre-certification process: A pre-certification is the review and certification of the medical necessity of any inpatient stay including medical surgical and behavioral health. This does not include outpatient services or observation stays up to 48 hours.

Pre-certification by the Plan is required for all Inpatient Services, including Emergency admissions within seventy-two (72) hours after admission.

To initiate a pre-certification, a facility may call 800-342-6510 to talk directly to a nurse or fax the admission information and clinicals to 406-532-1501. Determinations are made within 24 hours of receipt of all information.

Please note, the language below is in the Disney Signature Benefits Plan document:

NOTE: PRE-CERTIFICATION OF BENEFITS IS NOT A GUARANTEE OF PAYMENT OF THE CLAIM(S). ELIGIBILITY FOR CLAIM PAYMENTS IS DETERMINED AT THE TIME CLAIMS ARE ADJUDICATED SINCE THE AMOUNT OF BENEFIT COVERAGE, IF ANY, IS SUBJECT TO ALL PLAN PROVISIONS INCLUDING, BUT NOT LIMITED TO, MEDICAL NECESSITY, PATIENT ELIGIBILITY, DEDUCTIBLES, COPAYMENTS AND ANY PLAN LIMITATIONS OR MAXIMUMS IN EFFECT WHEN THE SERVICES ARE PROVIDED. PROVIDERS AND COVERED PERSONS ARE INFORMED AT THE TIME CLAIMS ARE PRECERTIFIED THAT PRE-CERTIFICATION OF A COURSE OF TREATMENT BY THE PLAN DOES NOT GUARANTEE PAYMENT OF CLAIMS FOR THE SAME.