Understanding Precertification
As a member of Berkshire Health Partners, your employer has also provided you and
your family with a Medical Management Program
through Medicus Resource Management. The professional
staff at Medicus assists you in determining whether
proposed services are medically appropriate. The
Medicus program is not intended to diagnose or
treat medical conditions, guarantee benefits or
validate eligibility. Instead, the medical professionals
who answer inquiries focus on whether hospital
stays, proposed surgery or ambulatory procedures
are medically appropriate.
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
through Friday from 8 a.m. until 5 p.m. at 610-372-8417
or 800-647-2500. You may leave a message after
hours. Your call will be returned the following
business day.
Standard Precertification
List
You are required to call Medicus
prior to any of the following situations**
 Inpatient
Confinements |
Medical/Surgical
Mental Health
Rehabilitation |
Skilled Nursing
Substance Abuse |
| |
|
| Procedures |
Abdominoplasty (TummyTuck)
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 |
| |
|
| Home
Health Care |
Aide Care
Hospice |
Infusion therapy
Skilled Nursing |
| |
|
| DME |
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
| Other |
| Perinatology consults |
Pre-notification of all pregnancies
|
**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 concerning precertification
of a treatment or service.
What information will they
ask me for?
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|
|
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Name and social security 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
|
| 
