Precertification Guidelines for Members
Your employer has provided you and your family with a medical management program through Medicus Resource Management, Inc. (Medicus). Medicus assists you in determining whether proposed healthcare services, hospital stays, proposed surgery, or ambulatory procedures are medically appropriate. However, Medicus does not diagnose or treat medical conditions, guarantee benefits, or validate eligibility.
Some services must be pre-approved or precertified by Medicus staff members. Our standard recommended precert list is provided below. Please note that precertification lists may vary by employer. You should consult your specific benefits booklet for a complete description of your plan's requirements. Penalties may apply for noncompliance.
The Medicus office is open Monday–Friday from 8:00 AM - 5:00 PM E.D.T / E.S.T. at 610-372-8417 or 800-647-2500. You may leave a message after hours. Your call will be returned the following business day. If you have a medical emergency, seek treatment immediately and contact Medicus the next business day.
Precertification List
You are required to call Medicus prior to any of the following situations**
- Medical/Surgical
- Mental Health
- Rehabilitation Skilled Nursing
- Substance Abuse
Inpatient Confinements
- Aide Care
- Hospice
- Infusion Therapy
- Skilled Nursing
Home healthcare
- Abdominoplasty (Tummy Tuck)
- Adult Strabismus Surgery (Eyes)
- Bariatric Surgery
- Blepharoplasty (Eyes)
- Brachytherapy (Cancer Treatment)
- Cardiac Rehabilitation
- Chemotherapy
- External Counterpulsation Therapy (Cardiology)
- Initiation of Dialysis Therapy
- Occupational Therapy
- Orthognathic Surgery (Jaw) PET scans
- Physical Therapy
- Plasmapheresis
- Radiation Therapy
- Reduction Mammoplasty
- Referral to a Transplant Center
- Rhinoplasty / Septoplasty (Nose)
- Speech Therapy
- TMJ Surgery
- Uvulopalatoplasty (Palate/Sleep Apnea)
- Vision Therapy
Procedures
- Apnea Monitor
- Bone Growth Stimulators
- CPAP/BIPAP
- Hospital Beds
- Insulin Pumps
- Lymphedema Pumps
- Muscle Stimulators
- Orthotics - Custom Made
- Oxygen Therapy
- Patient lift / Stair Chairs
- UV Light Therapy
- Wheelchairs/ Scooters
- Out-of-Network and Tertiary Facility/Provider Referrals
Durable Medical Equipment
- Perinatology Consults
- Pre-notification of all pregnancies
Other
**NOTE: Precertification Lists may vary by employer. Please consult your specific benefits booklet for a complete description of your plan's requirement. Penalties may apply for non-compliance.
Be Prepared
The following questions and answers will help you to be prepared when you call Medicus Resource Management, Inc. (Medicus) concerning precertification of a treatment or service.
- Name and identification number of the covered employee
- Name of the patient who is seeking treatment
- Name, address, and telephone number of the admitting physician
- Name, address, and telephone number of the facility providing the services
- The scheduled date of service
What information will they ask me for?
- Elective Admissions/Procedures:
Call at least 5 working days prior to the date when services are scheduled - Emergency Admissions:
Notify Medicus within 48 hours of the admission - Obstetrical patients:
Precertify the delivery of your baby after your first visit to the obstetrician - Organ Transplants:
Call Medicus to be sure that the services are being provided by a contracted facility
