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Precertification Guidelines for Members

Your employer has provided you and your family with a medical management program through Medicus Resource Management, Inc. (Medicus), A Health & Lifestyle Management Company. Medicus assists you in determining whether proposed healthcare services, hospital stays, proposed surgery, or ambulatory procedures are medically appropriate. While you will receive written notification of the determination, Medicus does not diagnose or treat medical conditions, guarantee benefits, or validate eligibility. Standards used during the review process are available free of charge upon request.

Some services must be pre-approved or precertified by Medicus staff members. Our medical management team compiled a list of the most common percert services, which are below. Please note that precertification requirements 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.

    Inpatient Confinements

  • Medical/Surgical
  • Mental Health
  • Rehabilitation Skilled Nursing
  • Substance Abuse

    Home healthcare

  • Aide Care
  • Hospice
  • Infusion Therapy
  • Skilled Nursing

    Procedures

  • 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

    Durable Medical Equipment

  • 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

    Other

  • Perinatology Consults
  • Pre-notification of all pregnancies
  • Out-of-Network and Tertiary Facility/Provider Referrals

**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.

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.

Be Prepared

The following questions and answers will help you to be prepared when you call Medicus concerning precertification of a treatment or service.

    What information will they ask me for?

  • 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

    When should I call Medicus for precertification?

  • 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

To contact Medicus please call 800-647-2500 or 610-372-8417.