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prior approval when required by your CHIP coverage; and coordinate a program for
length of stay/service review. The purpose of these services is to determine whether
the confinement or surgery is medically necessary. Any non-emergency admission to a
hospital or skilled nursing facility as an inpatient must be precertified by the
Administrator’s UR program. Different rules apply for emergency confinements. Refer
to any specific CHIP benefit plan booklet that may be issued to you for details.
These provisions of your CHIP coverage are designed to insure that you get all the
necessary care you need in the most appropriate setting while preventing unnecessary
procedures and confinements that increase your charges but provide no benefit to you.
They also enable our Administrator’s UR program to help plan your discharge to your
home or a skilled nursing facility while determining whether any post-hospitalization care
is covered by your CHIP coverage. Precertification or prior approval does not constitute
a guarantee of benefits under your CHIP coverage for any confinements that are
precertified by the UR program as medically appropriate. Actual availability of benefits
is subject to eligibility and the other terms, conditions, limitations and exclusions of your
CHIP coverage, including any preexisting conditions limitation.
1. Preadmission Review of Inpatient Confinements. Preadmission review is
required when you are confined in a hospital or skilled nursing facility:
a) expenses incurred for days of confinement certified as medically
appropriate, benefits will be payable in accord with the provisions set forth
in the specific CHIP benefit plan booklet;
b) expenses incurred for days of confinement for which review does occur,
but which are not certified as medically appropriate, benefits for room and
board will not be payable, and benefits for other covered services will be
payable in accord with the provisions set forth in the specific CHIP benefit
plan booklet;
c) expenses incurred for days of confinement at a facility which is located
within either the State of Illinois or not more than 75 miles outside the
State of Illinois for which review does not occur, in addition to any penalty
imposed under item (b) above, benefits will be reduced by $500; and
d) expenses incurred for days of confinement and any other related
professional medical services at a facility which is located more than 75
miles outside the State of Illinois for which review does not occur, in
addition to any penalty imposed under item (b) above, benefits also will be
reduced by 20% of the rate of payment which would have been payable
had prior approval been received.
Any reduction in benefits described above cannot be used to satisfy any
deductible, out-of-pocket expense amount or out-of-network expense limit
contained in the specific CHIP benefit plan booklet.
Benefits will not be payable when days of confinement in a hospital or
skilled nursing facility are for medical or surgical services which are not:
(a) medically necessary; or (b) covered by your CHIP coverage.