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nursing facility are for medical or surgical services which are not: (a) medically necessary; or (b) covered by your CHIP coverage.
2. Hospital Preadmission Testing. For the Medicare Plan, and the non-HDHP Plans, expenses for hospital preadmission testing will be paid at 100% of usual and customary fees with no deductible if:
a) your physician determines that hospital confinement is necessary before the tests are performed;
b) tests are performed on an outpatient basis in connection with a covered hospital confinement within seven days of admission to a hospital as an inpatient;
c) the tests would be covered if performed during hospital confinement; and
d) the hospital where you are confined accepts the tests in lieu of tests which would have been performed during hospital confinement, and does not repeat the tests upon admission, unless your medical records show both the results of the preadmission tests and that repeated tests are medically necessary.
Hospital pre-admission testing benefits are payable same as any other medical tests (i.e., subject to the deductible and coinsurance) under the HDHP Plans.
3. Prior Approval. Prior approval is required in each of the following instances. Prior approval requires you to notify the Administrator’s UR by phone prior to receiving a service, drug or supply:
a) Durable Medical Equipment: If you intend to purchase or rent durable medical equipment, check first to see if the total overall cost of the item will be $500 or more. If so, prior approval is required. If written prior approval is not obtained from our Administrator, any expense incurred for the purchase or rental of durable medical equipment will not be covered.
b) Home Health Care: If your attending physician has ordered a plan of treatment for home health care, you must obtain prior approval. If prior approval is not obtained from our Administrator, any expense incurred as a result of home health care will not be covered.
c) Hospice Care: If your attending physician has ordered hospice care, you must obtain prior approval. If prior approval is not obtained from our Administrator, any expense incurred as a result of hospice care will not be covered.
d) Specified Organ or Tissue Transplants: To be eligible for benefits for any specified organ or tissue transplant (see next section), you must obtain our Administrator's prior written approval and use a Board-approved participating transplant center for that specific organ or tissue transplant. We will pay no benefits unless you have obtained prior approval in writing from our Administrator and comply with all of the terms, conditions and other requirements provided for in any specific CHIP benefit plan booklet that may be issued to you.
