2008 Case Management

Case management is an important part of managing Purdue’s health plans. The goal of case management is two-fold:

1) To help educate the patient and ensure that he or she receives appropriate care
2) To protect the medical plans from paying for services that are not medically necessary

One of the tools used for case management is precertification.

Precertification Requirements

Any time you or one of your covered dependents is to receive any of the services outlined below, you are responsible for contacting UMR Care Management at 1 (866) 795-6382 for pre-approval of the services. If you do not precertify these services, you will incur a $250 penalty. Additionally, if UMR Care Management determines that the services are not medically necessary or appropriate, you will be responsible for the entire bill.

• Inpatient stays in an extended care facility, a birthing center, or a hospital: All inpatient stays must be pre-certified with UMR Care Management. You must certify in advance when you know about an upcoming inpatient stay or within 48 hours after you are admitted for an unscheduled or emergency stay. Precertification is not required for the mother or the baby for maternity stays of less than 48 hours for a standard delivery or less than 96 hours for a Caesarian section delivery.
• Home health care: All home health care services must be pre-certified through UMR Care Management.
• Durable medical equipment: Equipment purchases of more than $500 and all equipment rentals must be pre-approved through UMR Care Management.
• Other services requiring precertification:

• Home infusion services
• Arthroscopic surgery
• Breast surgery, including biopsies
• Cardiac catheterization
• Laproscopic surgery
• Pacemaker insertion
• Prostate surgery
• Sinus surgery
• Outpatient chemotherapy
• Genetic testing
• Full body scans and heart scans