The CoverAmerica Gold Insurance plan has mandatory pre-certification requirements for certain services and treatments.
As per the plan the following expenses must always be pre-certified:
- Inpatient Treatment and or supply of any kind
- Any Surgery or Surgical Procedure
- Computerized Tomography (CAT Scan)
- Magnetic Resonance Imaging (MRI)
- Treatment in extended care facilities
- Durable Medical Equipment
- Artificial Limbs
- Contact Seven Corners Assist (at the telephone number shown in the policy or on the insurance I.D. card) as soon as possible before the expense is to be incurred;
- Comply with Seven Corners Assists instructions and submit any information or documents they require;
- Notify all physicians, hospitals and other providers that this insurance contains pre-certification requirements and ask them to fully co-operate with Seven Corners.
In the event of an emergency hospital admission, pre-certification must be made within 48 hours of the admission, or as soon as reasonably possible.
If you comply with the pre-certification requirements, the expenses will then be reviewed according to the policy terms to determine if the expenses are eligible to be paid. If you do not comply with the pre-certification requirements or if the expenses are not pre-certified, your expenses will be reviewed according to the policy terms. If they are determined to be eligible for payment, they will be reduced by 50%, then the deductible will be subtracted from the remaining amount, and finally the coinsurance will be applied.
Pre-Certification Does Not Guarantee Benefits
The fact that expenses are pre-certified does not guarantee either payment of benefits or the amount of benefits. Eligibility for and payment of benefits is determined after review of the policy terms, conditions, provisions and exclusions.
Concurrent Review For Inpatient stays of any kind, the Administrator will pre-certify a limited number of days of confinement. Additional days of Inpatient confinement may later be pre-certified if an Insured receives prior approval.