Precertifications

To take full advantage of your benefits as a member of Senior Care Plus, you must understand which services require precertification. You are responsible for ensuring that you notify Senior Care Plus before certain services and procedures are performed.

The following services may require precertification from Senior Care Plus:

• All inpatient hospitalizations
• All inpatient rehabilitation
• All same-day surgery
  • Diagnostic and screening colonoscopies do not require authorization
• Skilled Nursing Facility admissions
• Durable Medical Equipment over $100
• Home Health Services
• Transplant Services
• (excluding outpatient diagnostic testing, laboratory or x-ray)
• Pain-management services, including trigger-point injections
• Office visits to specialists
  • Excluding chiropractic and in-office procedures
• Please note: PPO does not require authorization for visits to specialists.
• Some medications also require authorization. Please refer to the formulary for information on specific medications.

Call our Customer Service Department at 775-982-3112 to request a precertification prior to obtaining the service or procedure.

Senior Care Plus performs Utilization Review only to precertify the medical necessity of the above services for the care and treatment of an illness or injury. Senior Care Plus will also review for alternative methods of medical care or treatment. Precertification by Senior Care Plus does not guarantee that all charges are covered under the policy. Charges submitted for payment are subject to all terms of the policy.

If a member fails to secure a precertification prior to receiving the services listed above, benefits are reduced to a 50 percent coinsurance level. This reduction is in addition to any other deductible and copayment under the policy.

It is important to remind your physician of these precertification requirements. Both you and your physician can contact our Customer Service Department to complete the precertification process.