|
Pre-certification
There is some confusion about the meaning of pre-certification. Because the AmeriCorps Health Benefits plan provides limited benefits and does not cover pre-existing conditions the meaning of "pre-certification" should be clearly understood.
What it means
The term "pre-certification" means:
- the member has been certified as eligible for coverage by the AmeriCorps Health Benefits plan and;
- this medical condition requires admittance to the hospital instead of outpatient care.
The pre-certification process also includes three other important factors:
- it documents that the hospital is in the provider network and, if it is not, provides notice to the hospital that the member will be responsible for those charges that exceed the cost paid by the plan (the member may have to pay);
- it provides warning that the AmeriCorps Health Benefits plan provides limited benefits and does not cover pre-existing conditions and;
- it verifies that "pre-certification" is not a guarantee of payment.
What it does NOT mean.
"Pre-certification" does not mean the procedure for which the member is admitted is guaranteed to be covered by the AmeriCorps Health Benefits plan. The plan will NOT cover pre-existing conditions and will NOT cover benefits excluded in the plan.
Does this make sense? (Member Responsibilities.)
Yes. The member is responsible for knowing what the plan covers and what it does not cover. When the member or hospital calls for "pre-certification" the Customer Service Representatives at Seven Corners explain to the member and to the hospital that "pre-certification" does not guarantee payment. Seven Corners' Customer Service Representatives carefully explain that the plan provides limited benefits and does not cover pre-existing conditions.
Following this verbal explanation a fax containing this information is sent to the hospital.
Seven Corners CANNOT promise that (payment for) a claim will be approved in advance because Seven Corners cannot know what the physician or hospital will include on the claim. To approve or deny a claim Seven Corners can only use the information that is on the claim or in the medical records. If the information on the claim is not sufficient to make a decision Seven Corners will then request all medical records relevant to the claim. It is not possible to know in advance what will be on the claim or in the medical records.
The AmeriCorps Health Benefits plan is a self-funded plan with limited benefits; it belongs to the Corporation for National and Community Service and is paid for with funds appropriated by Congress for the Corporation. It does not belong to an insurance company; there is no insurance company. It is not a health insurance plan.
The AmeriCorps Health Benefits plan is available on line at http://americorps.sevencorners.com/docs/guide.pdf
|
