Section 3. How you get care

In this section:

• Identification Cards
• Where You Get Covered Care
• What You Must Do To Get Covered Care
• How To Get Approval For:
  • Your Hospital Stay
  • Radiology/Imaging Procedures Precertification
  • Other Services

Identification cards	We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter. If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, contact us as follows: High Option: Call us at 800/222-APWU or write to us at P.O. Box 1358, Glen Burnie, MD 21060-1358 or through our Web site at www.apwuhp.com. Consumer Driven Option: Call Definity Health at 866/833-3463 or write to us at P.O. Box 740810, Atlanta, GA 30374-0810 or request replacement cards through the Web site at www.definityhealth.com.
Where you get covered care	You can get care from any "covered provider" or "covered facility." How much we pay — and you pay — depends on the type of covered provider or facility you use. If you use our preferred providers, you will pay less.
Covered providers	We consider the following to be covered providers when they perform services within the scope of their license or certification: Doctor – A licensed doctor of medicine (M.D.), a licensed doctor of osteopathy (D.O.), a licensed doctor of podiatry (D.P.M.), or, for certain specified services covered by this Plan, a licensed dentist, licensed chiropractor, or licensed clinical psychologist practicing within the scope of the license. Alternate Provider – Alternate providers are covered when performing certain specified services covered by this Plan and when such treatment is within the scope of the provider's license. Alternate providers are limited to licensed physical, occupational and speech therapists; licensed physician's assistants; Registered Nurses (R.N.); Licensed Practical Nurses (L.P.N.); Licensed Vocational Nurses (L.V.N.); and Certified Registered Nurse Anesthetists (C.R.N.A.). Other covered providers include a qualified clinical psychologist, clinical social worker, optometrist, audiologist, nurse midwife nurse practitioner /clinical specialist, and nursing school administered clinic. For purposes of this FEHB brochure, the term “doctor” includes all of these providers when the services are performed within the scope of their license or certification. Medically underserved areas. Note: We cover any licensed medical practitioner for any covered service performed within the scope of that license in the states OPM determines are “medically underserved.” For 2008, the states are: Alabama, Arizona, Idaho, Kentucky, Louisiana, Mississippi, Missouri, Montana, New Mexico, North Dakota, South Carolina, South Dakota, and Wyoming.
Covered facilities	Covered facilities include: Freestanding ambulatory facility An out-of-hospital facility such as a medical, cancer, dialysis, or surgical center or clinic, and licensed outpatient facilities accredited by the Joint Commission on Accreditation of Healthcare Organizations for treatment of substance abuse. Hospital Program of the Joint Commission on Accreditation of Healthcare Organizations, or Any other institution which is operated pursuant to law, under the supervision of a staff of doctors and twenty-four hour a day nursing service, and which is primarily engaged in providing: general inpatient care and treatment of sick and injured persons through medical, diagnostic and major surgical facilities, all of which must be provided on its premises or under its control, or specialized inpatient medical care and treatment of sick or injured persons through medical and diagnostic facilities (including X-ray and laboratory) on its premises, under its control, or through a written agreement with a hospital (as defined above) or with a specialized provider of those facilities. The term "hospital" shall not include a skilled nursing facility, a convalescent nursing home or institution or part thereof which 1) is used principally as a convalescent facility, rest facility, residential treatment center, nursing facility or facility for the aged or 2) furnishes primarily domiciliary or custodial care, including training in the routines of daily living.
What you must do to get covered care	It depends on the kind of care you want to receive. You can go to any provider you want, but we must approve some care in advance.
Transitional care	Specialty care: If you have a chronic or disabling condition and lose access to your specialist because we drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan, or lose access to your PPO specialist because we terminate our contract with your specialist for reasons other than cause, you may be able to continue seeing your specialist and receiving any PPO benefits for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the Program, contact your new plan. If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist and your PPO benefits continue until the end of your postpartum care, even if it is beyond the 90 days.
If you are hospitalized when your enrollment begins	We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our High Option begins, call our customer service department immediately at 800/222-APWU. For the Consumer Driven Option, please call Definity Health at 866/833-3463. If you are new to the FEHB Program, we will reimburse you for your covered services while you are in the hospital beginning on the effective date of your coverage.
	If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until: You are discharged, not merely moved to an alternative care center; or The day your benefits from your former plan run out; or The 92nd day after you become a member of this Plan, whichever happens first These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized family member's benefits under the new plan begin on the effective date of enrollment.
How to Get Approval for…
Your hospital stay	Precertification is the process by which – prior to your inpatient hospital admission – we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition. Unless we are misled by the information given to us, we won't change our decision on medical necessity. In most cases, your physician or hospital will take care of precertification. Because you are still responsible for ensuring that your care is precertified, you should always ask your physician or hospital whether they have contacted us.
Warning	We will reduce our benefits for the inpatient hospital stay by $500 if no one contacts us for precertification. If the stay is not medically necessary, we will not pay any benefits.
How to precertify an admission	High Option: You, your representative, your doctor, or your hospital must call at least 48 hours before admission. To precertify in Alabama, Alaska, Arkansas, Arizona, California, Colorado, Connecticut, District of Columbia, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Idaho, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Jersey, New Mexico, New York, Nevada, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Puerto Rico, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Virgin Islands, Washington, West Virginia, Wisconsin and Wyoming; call CIGNA at 800/582-1314. In Minnesota, call PreferredOne at 800/451-9597 to precertify. These numbers are available 24 hours every day. Consumer Driven Option: You, your representative, your doctor, or your hospital must call Definity Health at 866/333-4648 at least 48 hours before admission. This number is available 24 hours every day. If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the doctor, or the hospital must telephone the above number 48 hours following the day of the emergency admission, even if you have been discharged from the hospital. Provide the following information: Enrollee's name and Plan identification number Patient's name, birth date, and phone number Reason for hospitalization, proposed treatment, or surgery Name and phone number of admitting doctor Name of hospital or facility; and Number of planned days of confinement We will then tell the doctor and/or hospital the number of approved inpatient days and we will send written confirmation of our decision to you, your doctor, and the hospital.
Maternity care	You do not need to precertify a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section, then your physician or the hospital must contact us for precertification of additional days. Further, if your baby stays after you are discharged, then your physician or the hospital must contact us for precertification of additional days for your baby.
If your hospital stay needs to be extended:	High Option: If your hospital stay — including for maternity care — needs to be extended, you, your representative, your doctor or the hospital must ask us to approve the additional days by calling the precertification vendor for your state as shown above; CIGNA at 800/582-1314, PHCS at 800/661-7563 or PreferredOne at 800/451-9597. Consumer Driven Option: If your hospital stay — including for maternity care — needs to be extended, you, your representative, your doctor or the hospital must ask us to approve the additional days by calling Definity Health at 866/333-4648.
What happens when you do not follow the precertification rules	If no one contacted us, we will decide whether the hospital stay was medically necessary. If we determine that the stay was medically necessary, we will pay the inpatient charges, less the $500 penalty. If we determine that it was not medically necessary for you to be an inpatient, we will not pay inpatient hospital benefits. We will only pay for any covered medical supplies and services that are otherwise payable on an outpatient basis. If we denied the precertification request, we will not pay inpatient hospital benefits. We will only pay for any covered medical supplies and services that are otherwise payable on an outpatient basis. When we precertified the admission but you remained in the hospital beyond the number of days we approved and did not get the additional days precertified, then:: For the part of the admission that was medically necessary, we will pay inpatient benefits, but For the part of the admission that was not medically necessary, we will pay only medical services and supplies otherwise payable on an outpatient basis and will not pay inpatient benefits.
Exceptions	You do not need precertification in these cases: You are admitted to a hospital outside the United States and Puerto Rico. You have another group health insurance policy that is the primary payer for the hospital stay. Medicare Part A is the primary payer for the hospital stay. Note: If you exhaust your Medicare hospital benefits and do not want to use your Medicare lifetime reserve days, then we will become the primary payer and you do need precertification.
Radiology/Imaging Procedures Precertification	High Option: Radiology precertification is required prior to scheduling specific imaging procedures. We evaluate the medical necessity of your proposed procedure to ensure that the appropriate procedure is being requested for your condition. In most cases your physician will take care of the precertification. Because you are responsible for ensuring that precertification is done, you should ask your doctor to contact us. The following outpatient radiology services require precertification: CAT/CT - Computerized Axial Tomography MRI - Magnetic Resonance Imaging MRA - Magnetic Resonance Angiography NC - Nuclear Cardiology PET - Positron Emission Tomography
How to precertify a radiology/imaging procedure	For these outpatient studies; you, your representative or doctor must call MedSolutions before scheduling the procedure. The toll free number is 888/693-3298. Provide the following information: Patient's name, Plan identification number, and birth date Requested procedure and clinical support for request Name and phone number of ordering provider Name of requested imaging facility
Exceptions	You do not need precertification in these cases: You have another health insurance policy that is primary including Medicare Parts A&B or Part B Only The procedure is performed outside the United States or Puerto Rico You are inpatient hospital The procedure is performed as an emergency
Warning	We will reduce our benefits for these procedures by $100 if no one contacts us for precertification. If the procedure is not medically necessary, we will not pay any benefits.
Other services	Some services require prior approval (High Option) and some require pre-notification (Consumer Driven Option): Prior approval/pre-notification is required for organ transplantation. Call before your first evaluation as a potential candidate. Prior approval/pre-notification is required for surgical procedures which may be cosmetic in nature such as eyelid surgery (blepharoplasty) or varicose vein surgery (sclerotherapy). Prior approval/pre-notification is required for recognized surgery for morbid obesity (bariatric surgery) or for organic impotence. Prior approval/pre-notification is required for home health care such as nursing visits, infusion therapy, growth hormone therapy (GHT), rehabilitative therapy (physical, occupational or speech therapy) and pulmonary rehabilitation programs. Prior approval/pre-notification is required for durable medical equipment such as wheelchairs, oxygen equipment and supplies, artificial limbs and braces. Prior approval/pre-notification is required for certain classes of drugs. The Plan may have certain coverage limitations to ensure clinical appropriateness. For example, prescription drugs used for cosmetic purposes such as Retin A or Botox, may not be covered, a medication might be limited to a certain amount (such as the number of pills or total dosage) within a specific time period, or require authorization to confirm clinical use based on FDA labeling. In these cases you or your physician can begin the coverage review process by calling MEDCO Customer Service at 800/841-2734. See Section 5(f), page 46. High Option: Call CIGNA at 800/582-1314 in Alabama, Alaska, Arkansas, Arizona, California, Colorado, Connecticut, District of Columbia, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Idaho, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Jersey, New Mexico, New York, Nevada, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Puerto Rico, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Virgin Islands, Washington, West Virginia, Wisconsin and Wyoming; or call PreferredOne at 800/451-9597 in Minnesota if you need any of the services listed above. Consumer Driven Option: Call Definity Health at 866/333-4648 if you need any of the services listed above. Prior approval is also required for mental health and substance abuse benefits, inpatient or outpatient, in-network or out-of-network. Under the High Option and the Consumer Driven Option, call ValueOptions at 888/700-7965.

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