Utilization Management
Coventry Health Care's Utilization Management program is designed
to help you evaluate the medical necessity of your recommended
treatment and identify whether or not a procedure can be
certified under the terms of your plan.
Precertification Review
If your health plan requires precertification, you will need to
receive approval from Coventry Health Care before you obtain certain
treatments, services and/or supplies in order for you to qualify
for full medical benefits.
During the precertification review process, our staff can help
you or your physician answer important questions, such as:
- Is the treatment appropriate for the diagnosed condition or
symptom?
- Is the proposed level of care necessary or could services be
safely and effectively provided at a lower, less costly level of
care?
- Is there a less risky, medically appropriate treatment
alternative?
- Are there any extra expenses included as part of the
treatment?
- Is the proposed treatment or service a covered benefit under
your plan?
- Are the proposed health care providers considered in-network
providers under your plan?
Of course, any decision regarding treatment is left up to you
and your physician. Precertification review can help you make a
more informed decision before undergoing any recommended
treatments.
How Precertification Review Works
- If your physician recommends a treatment or service that
requires precertification, remind him or her that you will need
to obtain precertification.
- You or your physician should call the precertification phone
number listed on your ID card 7 days prior to a scheduled
treatment, but at least one business day prior to the treatment.
If you are admitted to the hospital on an emergency basis, call
the precertification phone number by the second business day
following admission.
- When you call, the precertification staff will review the
diagnosis, recommended treatment and proposed level of care. They
will compare proposed procedures to those of medically accepted
guidelines for treating your condition.
- If necessary, the review staff will contact your physician
for additional medical information.
- You, your physician and/or the hospital will be notified in
writing of the review decision.
If You Have Questions
Please refer to your Benefits Document for your plan's specific
precertification requirements or call the toll-free Customer
Service phone number on your ID card.
