Predetermination for Medical Necessity - CHMCA

Predetermination for medical necessity is the responsibility of the ordering physician. However, it is up to the Employee Health Plan (EHP) member’s benefit to remind their physician that this is a requirement so that claims payment issues can be avoided.

If you have questions pertaining to predetermination issues, CHN Care Management business hours are from 8 a.m. to 4:30 p.m. EST, Monday through Friday. If an urgent situation occurs, a CHN Care Manager is on call after standard business hours and can be reached by calling 216-986-1050 or toll-free at 1-888-246-6648.

The following list includes those services that MUST receive predetermination for medical necessity prior to being rendered EXCEPT for emergency/urgent situations.
Inpatient Services

• Acute Rehabilitation Admission
• Elective Hospital Admission*
• Out-of-Network and Out-of-Area Care (All)**
• Skilled Nursing Facility (SNF)/Transitional Care Unit (TCU)/Sub-Acute Admission

*The CHN Care Management goal is to transition all care into a Tier 1 or Tier 2 Provider. Refusal to transition will result in charges being paid as Tier 3 expenses.

Outpatient Services

• Experimental or Investigational Procedures
• Home Care
• Home Use of Tocolytic Agents/Home Use of Uterine Monitoring
• Human Organ or Bone Marrow Transplant
• Potentially Cosmetic Procedures
• Durable Medical Equipment (DME)*:

• Cochlear implants
• Continuous passive motion machines
• Electric wheelchairs
• Extension/Flexion (dynamic and bi-directional) devices
• Full spectrum light boxes
• Fully automatic beds
• High-end (hinged) braces
• High-end prosthetics
• Home oxygen therapy
• Home CPAP or BiPap
• Insulin pumps
• Low air loss beds
• Non-standard size wheelchairs – lightweight/heavyweight
• Osteogenesis stimulators
• Pneumatic compression devices
• Scooters
• Speech assistance device

*Reimbursement for DME will be made at the established rate for standard equipment. Any rate differential for “deluxe” equipment will be the member’s responsibility.

Notification to CHN

• Hospice – CHN notification for authorization

Services Subject to Review

• Gastric Bypass Surgery – Gastric Bypass Surgery is a covered benefit under the Plan for members who have met the medical necessity criteria and have been approved by the CHN Care Management department prior to services being rendered. Members should contact CHN Care Management once they have completed the pre-surgery workup and have received approval from a network bariatric surgeon.

If the member does not meet the medical necessity criteria and the gastric bypass procedure is denied, the member will be responsible for the cost of the pre-surgery workup. The workup may include diagnostic and laboratory tests, assessments by endocrinology, nutrition, psychiatry/psychology, general surgery, and possibly other specialties such as cardiology.