Pre-Certification of Hospitalization

The treating licensed Doctor must consult with the Utilization Review Organization prior to any Hospitalization. It is the Covered Person’s or the Covered Person’s representative’s responsibility, not the attending Doctor’s, to contact the Utilization Review Organization. In the case of life- and/or organ-threatening situations, the consultation must take place as soon as reasonably possible. If such prior notification is not given, the Company will reduce payment for such claims by $750 of the Eligible Expenses. To pre-certify a hospitalization or diagnosis or treatment method, call First Health Network (FHN) at 1-800-572-5508.

The following Hospitals and Urgent Care Centers are First Health Network (FHN) facilities:

• Saint John’s Health Center.................................................1-310-829-5511
  Emergency Room................................ ............................1-310-829-8212
  2121 Santa Monica Blvd. (Main Entrance)
  2128 Arizona Avenue (Emergency Room Entrance)
  Santa Monica, CA 90404

Please be aware that if a Covered Person is treated at a PPO Hospital, it does not mean that all providers at that Hospital are PPO providers. In addition, if a Covered Person is referred by a PPO provider to another provider or facility, it does not mean that the provider or facility to which the Covered Person is referred is also a PPO provider. For instance, when a network provider refers a Covered Person to a lab for tests, he or she should make sure it is a network lab. Also, if a Covered Person has surgery, he or she should make sure the anesthetist is a network provider or he or she will be required to pay the higher coinsurance.

Health Care Links:

• Eligibility
• When coverage begins and ends
• Refund Policy
• Refund Request
• Definitions
• Student Health Service
• Benefit Schedule
• Non-Duplication of Benefits
• Miscellaneous Benefits
• Accidental Death & Dismemberment
• General Exclusions
• Preferred Provider Organization (PPO)
• Pre-Certification of Hospitalization

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